jINSOMNIA 


AND    ITS   THERAPEUTICS? 


A*.  W.  MACFARLANE,  M.D., 

Fellow  of  the  Royal  College  of  Physicians,  EdinBurgh  ;  Fellow  of  the  Royal  Medical  and 
Chirurgical  Society  of  London  ;  Examiner  in  Medical  Jurisprudence  in  the  Uni\-ersity 
of  Glasgow ;    Honorary    Consulting    Physician    (late    Physician)    Kilmarnock 
Infirmary ;  Formerly   Examiner  in   Medicine  and  Clinical   Med- 
icine in  the  University  of  Glasgow,  etc.,  etc. 


REPRINTED  FROM  WOOD'S  MEDICAL  AND  SURGICAL  MONOGRAPHS. 


NEW  YORK 
WILLIAM  WOOD  AND  COMPANY 

1891 


CONTENTS. 


CHAPTER  I. 

PACK 

The  Physiology  of  Sleep,      .        . .        11 

The  Brain  and  Nervous  System, 

The  Effects  of  Sleep  upon  the  Body,  .        .        .        .        .        . 

The  Depth  of  Sleep,        ......... 

The  Causation  of  Sleep, 

Dreams, 

CHAPTER  II. 

General  Remarks  on  Insomnia, 38 

Cardiac  and  Vaso-motor  Centres  in  the  Medulla  Oblongata,  .  46 

Conditions  which  Influence  Sleep  and  Sleeplessness,       .        .  50 

CHAPTER  III. 

Insomnia  Depending  upon  Affections  of  the  Nervous  System,      .  74 

Overwork, 74 

Shock, 84 

Depressing  Emotions, 87 

CHAPTER  IV. 
Insomnia  Depending  upon  Affections  of  the  Nervous  System, 

Continued, 95 

Neurasthenia, 95 

CHAPTER  V. 
Insomnia  Depending  upon  Affections  of  the  Nervous  System, 

Continued, Ill 

Hysteria,  ....  Ill 

Hypochondriasis, 114 

Insanity, 118 

Myxcederna,      ...  124 


iv  Contents. 

CHAPTER  VI. 

PAGE 

Insomnia  Depending  upon  Affections  of  the  Nervous  System, 

Continued, 125 

Insomnia  Depending  upon  Spasmodic  Neuroses,      .        .        .  125 

Insomnia  from  Paroxysmal  Neuroses, 128 

CHAPTER  VII. 

Insomnia  Depending  upon  Affections  of  the  Nervous  System, 

Continued, 137 

From  Affections  of  the  Brain  and  its  Membranes,     .        .        .137 
Insomnia  Depending  upon  Affections  of  the  Spinal  Cord, 
Nerves,  etc., . 147 

CHAPTER  VIII. 

Insomnia  Depending  upon  Affections  of  the  Nervous  System, 

Concluded, 151 

Insomnia  Depending  upon  Toxic  Agents,  Alcohol.  Morphine, 
Chloral,  Cocaine,  Tea  and  Coffee,  Tobacco,    ....      151 

CHAPTER  IX. 

Insomnia  Depending  upon  Affections  of  the  Alimentary  Canal,  .  166 

Gastric  Dyspepsia,  .        . 166 

Intestinal  Dyspepsia, 188 

Constipation,   . 192 

Intestinal  Worms, '    .        .        .        .  197 

CHAPTER  X. 

Insomnia  Depending  upon  Affections  of  the  Liver,         .        .        .      198 

Functional  Disorders  of  the  Liver, 198 

Jaundice, 202 

CHAPTER  XI. 

Gout,  its  Symptoms  and  Treatment,  with  Special  Reference  to 

Insomnia, 205 

Acute  Gout, 209 

Irregular  Gout, 210- 

CHAPTER  XII. 

Insomnia  Depending  upon  Affections  of  the  Circulatory  System,  .      229 


Contents.  \ 

CHAPTER  XIII. 

PAGE 

Insomnia  Depending  upon  Affections  of  the  Respiratory  System,      248 

CHAPTER  XIV. 

Insomnia  Depending  upon  Febrile  and  General  Diseases,      .        .      265 

CHAPTER  XV. 

Insomnia  Depending  upon  Affections  of  the  Urinary  System,      .       281 

CHAPTER  XVI. 
Insomnia  Peculiar  to  Females, 289 

CHAPTER  XVII. 
Baths— Electricity, 297 


INSOMNIA    AND    ITS    THERA- 
PEUTICS. 


CHAPTER  I. 

THE  PHYSIOLOGY   OF  SLEEP. 

"I  wish  I  could  write  a  chapter  upon  sleep;  it  is  a  fine  subject."— 
"  Tristram  Shandy." 

"Life's  nurse,  sent  from  heaven  to  create  us  anew  day  by  day." — 
READE. 

As  we  cannot  satisfactorily  study  sleeplessness  unless  we 
form  some  conception  of  sleep,  it  is  proposed  to  review  briefly 
a  few  points  connected  with  its  physiology,  such  as  .will  assist 
in  illustrating-  the  pathology  of  the  process.  No  attempt  will 
be  made  to  examine  all  the  varied  details  of  the  subject,  or  to 
shed  any  new  light  upon  the  mystery  in  which  it  is  still  en- 
shrouded ;  our  task  being  the  discussion  of  sleeplessness,  and 
not  the  solution  of  the  enigma  of  sleep. 

Sleep,  the  familiar  yet  mysterious  condition  of  repose  in 
which  our  consciousness  is  in  abeyance,  received  attention  in 
the  early  days  of  Hippocrates  and  Galen;  and  ever  since  it 
has  excited  the  interest  of  numerous  careful  and  able  investi- 
gators. Among  these  may  be  named  Bichat,  Binns,  Blumen- 
bach,  Braid,  Browne,  Brown-Sequard,  Brunton,  Cappie,  Car- 
penter, Cheyne,  Denby,  Dickson,  Donders,  Durham,  Ehrlich, 
Ehrmann,  Flemming,  Fox,  Foster,  Granville,  Hall,  Haller, 
Hammond,  Hartley,  Holland,  Jackson,  Kohlschiitter,  Kuss- 
maul,  Landois,  Lewis,  Lyman,  McKendrick,  Macnish,  Marvaud, 
Mitchell,  Moore,  Mosso,  Obersteiner,  Philip,  Playfair,  Pfliig- 
ger,  Ranke,  Richardson,  Salathe,  Savory,  Sieveking,  Sommer, 
Tenner,  Verheyen,  Vulpian,  Waller,  and  Willis.  Each  of  these 
observers  has  added  his  quota  to  the  general  fund  of  knowl- 


2  Insomnia  and  its   Therapeutics. 

edge,  while  some  have  advanced  theories  which  to  them  ap- 
peared to  interpret  the  nature  of  sleep.  No  one  of  these  ex- 
planations is  as  yet  recognized  as  affording-  a  satisfactory  or 
final  solution  of  the  changes  that  distinguish  a  brain  awake 
or  functionally  active,  from  one  asleep  or  functionally  tran- 
quil. Their  combined  observations,  however,  particularly 
those  made  during  the  last  thirty  or  forty  years,  have  ren- 
dered tolerably  apparent  the  nature  of  the  modifications 
which  occur  in  the  brain  in  the  course  of  sleep,  whether  these 
be  causative,  concomitant,  or  consequent.  Notwithstanding 
their  failure  to  unfold  definitely  the  constitution  of  sleep,  a 
careful  survey  of  the  accumulated  facts  will  serve  to  indicate 
the  character  of  the  various  pathological  conditions  which 
give  rise  to  insomnia. 

THE  BRAIN  AND  NERVOUS  SYSTEM. 

The  condition  of  an  animal  asleep  has  been  likened  to  "  one 
robbed  of  its  cerebral  hemispheres,"  capable  only  of  excito- 
motor  acts.  The  nervous  system,  as  a  whole,  is  in  a  quiescent 
state;  its  functions  are  curtailed,  and  those  which  persist  are 
carried  on  in  a  modified  manner. 

The  psychical  centres  in  the  convolutions  of  the  brain  are 
functionally  active  during  mental  operations.  These  have 
not,  like  the  motor  centres,  been  definitely  localized,  but  their 
physiological  (if  hypothetical)  existence  cannot  be  questioned ; 
they  embrace  intellectual,  emotional,  and  volitional  centres. 
Activity  originating  in  these  is  coincident  with  molecular 
changes  in  the  cerebral  cells,  changes  which  are  the  sources 
of  thought,  emotion,  and  volition.  The  nature  of  the  molecular 
metamorphosis  is  unknown,  but  that  is  no  reason  for  doubting 
its  occurrence.  During  sleep  this  molecular  activity  ceases, 
and  simultaneously,  mental  operations  are  suspended,  and 
consciousness  and  volition  are  in  abeyance. 

The  endless  variety  in  the  character  and  complex^  of  our 
cerebral  activities  implies  the  existence  of  a  like  multiplicity 
of  centres.  These  possess  the  most  diverse  functions,  but  all 
communicate  one  with  another,  by  means  of  elaborate  and  in- 
tricate arrangements,  and  also  with  the  special  sensory  and 
motor  areas,  so  as  to  enable  them  to  co-operate  in  a  correlated 
manner.  It  follows,  that  during  waking  moments  the  whole 


Insomnia  and  its   Therapeutics.  3 

of  these  centres  cannot  be  in  action  at  one  time ;  on  the  con- 
trary, that  a  certain  proportion  must  be  in  a  state  of  repose. 
It  seems  probable  that  during  sound  sleep  they  are  all  at 
rest;  if  a  limited  number  are  active,  light  sleep  and  dreams 
are  the  result;  if  any  considerable  number  are  in  function, 
sleep  is  rendered  impossible. 

The  motor  and  sensory  centres  likewise  subside  into  tran- 
quillity; the  latter  becoming  incapable  of  perceiving  slight  or 
ordinary  sensations,  while  their  corresponding  nerves  trans- 
mit impressions  in  a  slow  and  imperfect  way. 

The  great  nervous  centres  in  the  medulla  oblongata  which 
are  mainly  concerned  with  the  carrying  on  of  respiration  and 
circulation,  are,  so  far  as  is  compatible  with  life,  asleep. 

The  spinal  cord  also  is  less  active,  and  reflex  movements 
can  only  be  produced  in  response  to  more  powerful  excitations 
than  would  be  required  during  waking  moments,  and  these 
movements  are  slowly  performed.  This  is  probably  due  to 
the  fact  that  spinal  nerves  transmit  impressions  during  sleep 
in  a  languid  and  incomplete  manner.  Reflex  impulses  always 
bear  some  relation  to  the  intensity  of  the  excitation  and  to 
the  depth  of  sleep. 

The  condition  of  the  sympathetic  nervous  system  during 
sleep  is  uncertain.  It  has  not,  as  yet,  been  definitely  ascer- 
tained. 

Briefly  summarized,  during  sleep  the  brain,  ganglia,  me- 
dulla, and  cord  are  in  a  state  of  repose ;  and  the  work  of  the 
economy  is  conducted  with  the  smallest  possible  expenditure 
of  energy. 

A  good  illustration  of  the  extent  to  which  this  elaborate 
system  is  involved  is  to  be  found  in  the  following  remarks  of 
Mr.  Erichsen :  "  Those  who  are  asleep  at  the  time  of  the  acci- 
dent very  commonly  escape  concussion  of  the  nervous  system. 
They  may,  of  course,  suffer  from  direct  and  possibly  from  fatal 
injury  to  the  head  or  trunk;  but  the  shock  or  jar,  that  pecu- 
liar vibratory  thrill  of  the  nervous  system  arising  from  the 
concussion  of  the  accident,  is  frequently  not  observed  in  them, 
while  their  more  wakeful  and  less  fortunate  fellow-travellers 
may  have  suffered  severely  in  this  respect." 

Sleep  the  Time  favorable  for  Recuperation. — Nervous 
activit}-,  of  whatever  form  it  may  be,  is  invariably  attended 
by  the  consumption  of  the  potential  energy  which  exists  in 


4  Insomnia  and  its  Therapeutics. 

.nervous  tissues;  and  also  by  a  deposition  of  detritus  in  these 
parts,  in  quantities  corresponding1  to  the-  amount  of  work 
done.  This  activity  is  followed  in  a  longer  or  shorter  time  by 
a  feeling-  of  exhaustion,  which  suggests  repose,  and  is  only  re- 
lieved by  sleep.  So  that  during-  sleep,  in  addition  to  the  fact 
that  the  functions  of  the  nervous  system  cease,  so  far  as  it  is 
possible,  the  products  of  its  metabolism  are  excreted,  and  its 
potential  energy  is  recuperated. 

Onset  of  Sleep  Gradual. — Bichat  long-  ago  pointed  out, 
that  "  Sleep  general  was  made  up  of  many  particular  sleeps ;" 
that  it  did  not  invade  the  whole  of  the  organs  at  once,  but 
that  the  cerebrum,  sensorium,  spinal  cord,  and  the  various 
organs  and  muscles  must  jointly  and  severally  repose  for 
sleep  to  be  sound  and  complete.  Excitability  of  one  or  more 
of  these  systems  disturbs  the  repose  of  the  whole  body,  and 
insomnia  results.  In  this  way  we  comprehend  the  importance 
of  using  daily  all  the  separate  parts  in  something1  like  equal 
proportion  if  good  sleep  is  to  be  secured. 

Sleep  is  preceded  by  a  series  of  indefinite  and  obscure  sen- 
sations, which,  collectively,  are  universally  recognized  as  pre- 
monitory intimations  that  it  is  required  by  the  body.  It 
usually  comes  on  gradually,  one  set  of  centres  in  the  brain 
being  obscured  after  another,  generally  in  definite  order,  until 
all  are  involved. 

The  Motor  Centres  are  first  Invaded. — These  are  local- 
ized by  Ferrier  in  the  parietal  and  post-frontal  regions.  We 
find  that  one  group  of  muscles  after  another  becomes  relaxed 
until  the  body  assumes  the  horizontal  posture;  and  finally 
real  slackening  of  the  muscular  fibres  is  produced,  nowhere 
better  seen  than  in  the  diminution  of  tension  which  occurs  in 
the  firmly  contracted  muscles  of  a  hemiplegic  limb  during 
sleep.  The  only  exception  to  this  rule  is  in  the  case  of  the 
sphincters,  which  remain  contracted,  although  those  of  the 
eyelids  occasionally  fail  to  contract  firmly,  as  some  children 
sleep  with  their  eyes  partially  open  in  health,  and  they  more 
frequently  do  so  when  they  are  ill.  (In  disease,  even  in  tetanus, 
the  muscular  system  relaxes  during  sleep;  although  Professor 
Gairdner,  of  Glasgow,  recently  recorded,  in  a  case  of  severe 
chorea,  the  remarkable,  if  not  unique  fact,  that  "  the  opistho- 
tonic  attitude  was  maintained  even  during  sleep/' — "  Lancet," 
1889.) 


Insomnia  and  its   Therapeutics.  5 

The  motor  centres  in  the  brain  fall  asleep  before  those  in 
the  spinal  cord,  so  that  the  normal  inhibitory  influence  exer- 
cised by  the  former  is  for  the  time  being  in  abeyance;  and 
prior  to  the  subsidence  of  activity  in  the  cord  itself,  there  is  a 
tendency  to  spasmodic  action  of  the  muscles,  causing  exag- 
gerated acts,  and  slight  convulsive  movements  in  the  limbs 
or  in  the  whole  body.  Sleep  is  the  time  most  favorable  for 
the  exhibition  of  many  of  the  vagaries  of  the  nervous  system 
which  involve  muscular  movements;  epileptic  seizures,  con- 
vulsive attacks,  and  certain  reflex  acts  being  of  frequent 
occurrence. 

Sleep  next  extends  to  the  centres  for  psychical  operations 
in  the  hemispheres  of  the  brain;  the  will  ceases  to  control  the 
working  of  the  intellectual  faculties,  and  the  powers  of  per- 
ception grow  less ;  the  mind,  no  longer  inhibited  from  within 
or  corrected  from  without,  revels  in  absurdities,  until  at  length 
all  intellection  terminates,  or,  at  least,  no  knowledge  of  it  is 
retained. 

The  centres  for  the  special  senses,  each  in  its  turn,  and 
usually  in  the  order  enumerated  below,  become  progressively 
inactive,  failing  to  perceive  sensations  of  an  ordinary  kind, 
while  their  special  nerves  transmit  impressions  feebly. 

Professor  Ferrier  has  thus  localized  the  various  sensory 
centres. 

Vision. — That  of  vision  is  situated  in  the  occipito-angular 
region.  The  eyelids  close ;  the  e37eballs  turn  upward  and  in- 
ward in  the  orbits,  as  if  to  exclude  the  light;  and  the  pupils 
contract,  the  extent  of  this  contraction  being  an  indication  of, 
and  in  ratio  to,  the  depth  of  the  sleep.  External  excitations, 
either  through  the  skin  or  other  sensory  organs,  cause  the 
pupils  to  dilate  to  some  extent,  and  that  although  the  stimu- 
lation be  so  slight  as  to  fall  far  short  of  awaking  the  sleeper. 
This  phenomenon  varies  at  different  periods  of  sleep.  An 
excitation,  which  during  light  sleep  would  suffice  to  awaken 
the  sleeper,  only  causes  dilatation  of  the  pupils,  during  deep 
sleep. 

According  to  Plotke,  the  pupils  dilate  widely  in  the  act  of 
awaking. 

Oscillating  movements  of  the  eyeballs  are  common  in  chil- 
dren during  sleep. 

Hearing. — The  centres  for  hearing,  which  are  situated  in 


6  Insomnia  and  its   Therapeutics. 

the  superior  temporo-sphenoidal  convolutions,  only  respond  to 
very  pronounced  sounds  during  sleep.  This  sense  has  been 
utilized  for  the  purpose  of  estimating1  the  depth  of  the  process. 
Noises  frequently,  though  not  necessarily,  prevent  sleep;  and 
loud  noises  often  fail  to  arouse  a  sleeper,  while  an  accustomed 
or  expected  noise  or  sound  readily  does  so.  For  example,  if 
an  alarm-clock  rings  out,  by  accident,  hours  before  it  should 
do  so,  it  awakens  the  sleeper  at  once.  This  is  probably  due  to 
the  channels  and  centres  which  convey  and  perceive  familiar 
sounds  offering  less  resistance  to  their  transmission  and  re- 
ception, than  those  which  conduct  and  register  other  sounds. 
Certain  it  is,  that  a  sleeping  dog  will  awake  at  the  casual 
mention  of  his  name  in  the  course  of  conversation,  which  had 
not  previously  attracted  his  attention. 

Monotonous  sounds  are  not  perceived  after  a  time,  the 
centres  for  hearing  either  getting  accustomed  to  them,  or 
their  receptivity  becoming  lessened.  Their  cessation  alone 
attracts  attention :  for  instance,  in  night  travelling  it  is  usu- 
ally the  stopping  of  the  train,  or  the  interruption  of  the  noise, 
that  interferes  with  sleep.  Such  monotonous  sounds  as  read  ing 
slowly  in  one  tone  of  voice,  the  dropping  of  water,  soft  music, 
a  pleasant  murmur,  have  all  been  recommended  as  aid's  to 
sleep,  and  are  of  undoubted  efficacy.  Singing  a  lullaby  and 
monotonously  patting  a  child  are  the  popular  methods  of  woo- 
ing sleep.  It  has  been  proposed  in  America  to  court  sleep  by 
means  of  a  humming-top  worked  by  clock-work. 

Smell, — The  seat  of  this  sense  is  probably  in  the  tip  of  the 
temporo-sphenoidal  lobe.  For  the  keen  perception  of  odors 
it  is  necessary  that  the  fragrant  particles  should  be  dissolved 
in  the  mucous  secretion  of  the  Schneiderian  membrane.  Mu- 
cus is  n'ot  secreted  in  any  quantity  by  this  membrane  during 
sleep,  and  in  consequence  of  its  absence,  the  sense  is  so  enfee- 
bled that  even  offensive  materials  held  to  the  nostrils  fail  to 
waken  many  sleepers,  although  cases  have  been  recorded 
where  abominable  odors  have  awakened  persons  who  were 
slumbering  soundly;  the  stimulus,  however,  must  be  a  power- 
ful one.  Upon  awaking,  the  secretion  of  the  Schneiderian 
membrane  reappears,  and  the  centre  for  smell  resumes  its 
function.  Odors  of  various  kinds  prevent  sleep;  excessively 
minute  particles  of  a  volatile  substance  being  capable  of  per- 
ception by  the  radicles  of  the  olfactory  nerve.  In  the  case 


Insomnia  and  its   Therapeutics,  j 

of  musk,  for  example,  Kirke  quoting-  Valentine  states  that 
TTfFTro  <nnnr  °f  a  grain  can  be  so  detected. 

Taste.  —  This  is  localized  in  the  region  of  the  subiculum 
cornu  ammonis.  It  seems  probable  that  this  sense  is  modified 
during1  sleep,  though  it  is  difficult  to  determine  this  with  ac- 
curacy, as  the  conclusions  are  apt  to  be  vitiated  by  the  sense 
of  touch.  The  secretion  of  saliva  is  arrested,  and,  if  the  nos- 
trils are  unobstructed,  the  mouth  is  closed. 

Touch.  —  This  sense  is  located  in  the  hippocampal  and 
neighboring-  temporo-sphenoidal  regions.  The  centre  being 
deeply  situated  in  the  brain,  retains  its  activity  longer  than 
any  of  the  others.  Reflex  acts  can  always  be  excited  ;  their 
vigor  depending  upon  the  strength  of  the  stimulus,  the  degree 
of  sensitiveness  of  the  part  stimulated,  and  the  depth  of  sleep. 

The  centres  in  the  medulla,  which  are  not  entirely  oblivi- 
ous, work  at  the  lowest  rate  of  tension  compatible  with  life. 

Sleep  having  progressively  included  these  various  portions 
of  the  nervous  system,  it  is  said  to  be  profound,  and  no  act  of 
volition  can  modifj7  or  terminate  it. 

If  the  inception  of  sleep  be  considered,  it  will  be  apparent 
that  the  centres  situated  highest  in  the  cerebrum  are  the  first 
invaded,  while  those  at  a  lower  level  are  successively  included. 
This  may  depend  upon  the  centres  growing  inactive  consecu- 
tively (according  to  their  position),  and  ceasing  to  attract  a 
working  supply  of  blood  ;  or  it  may  arise  from  the  vascular 
supply  of  the  centres  becoming  lessened,  relatively  to  their 
distance  from  the  heart. 


THE  EFFECTS  OF  SLEEP  UPON  THE  BODY. 

The  Circulation.  —  From  the  days  of  Hippocrates  it  was 
believed  that  the  heart  pulsated  with  greater  force  and  fre- 
quency during  sleep  than  in  the  waking  state.  But  the  re- 
verse is  the  case.  The  pulse  beats  more  slowly  and  less 
strongly  while  one  is  asleep,  the  number  of  contractions  de- 
creasing on  an  average  from  ten  to  twenty  per  minute;  the 
same  phenomenon  is  noticed  in  those  who  sleep  by  day  and 
work  by  night.  The  recumbent  posture  accounts  in  part  for 
this.  Dr.  Wilks,  writing  in  Hilton  Fagge's  "  Principles  and 
Practice  of  Medicine/'  quotes  Tufnell  as  having  found  that,  in 
one  patient,  the  difference  in  the  frequency  of  the  pulse  was 


8  Insomnia  and  its  Therapeutics. 

thirty-five  beats  per  minute,  equal  to  fifty  thousand  in  the 
twenty-four  hours,  in  the  lying  as  compared  with  the  sitting 
posture.  The  realty  important  factor,  however,  in  the  causa- 
tion of  the  slowing-  of  the  pulse  during  sleep,  is  to  be  found  in 
the  weakened  functions  of  the  centres  in  the  medulla,  leading 
to  diminished  innervation  of  the  heart,  the  arterial  tension 
being  at  the  same  time  lowered.  This  is  more  marked  in 
children  than  in  adults.  The  pulse  is  sometimes  irregular  in 
healthy  children  during  sleep. 

In  pathological  conditions,  the  pulse  rate  is  diminished 
during  sleep,  the  exceptions  being  in  cases  of  great  prostra- 
tion without  elevation  of  temperature,  when  its  frequency  may 
be  accelerated.  Owing  mainly  to  the  depressed  state  of  the 
circulation,  palpitation  frequently  comes  on  during  sleep,  and 
hemorrhages  of  various  kinds  are  also  apt  to  occur. 

Respiration. — During  sleep,  the  respiratory  centres  being 
in  a  comparatively  inactive  condition,  the  respirations  number 
on  an  average  four  less  per  minute  than  at  other  times,  the 
inspirations  being  shallower,  and  chiefly  thoracic,  owing  to 
the  inactivity  of  the  diaphragm.  On  application  of  a  stimu- 
lus which,  though  interfering  with  sleep,  falls  far  short  of 
awaking  the  sleeper,  the  respirations  change  in  character,  ap- 
proaching more  nearly  those  of  the  waking  state;  and  when 
sleep  actually  terminates  the  breathing  becomes  deeper, 
quicker,  and  abdominal.  The  depth  of  sleep  can  be  gauged, 
by  noting  the  character  of  the  respirations,  and  occasionally 
the  rhythm  becomes  that  known  as  Cheyne-Stokes  without 
its  having  any  special  significance. 

In  diseases,  the  respirations  decrease  in  frequency  during 
sleep,  though  in  cases  of  prostration,  similar  to  those  referred 
to  in  the  last  paragraph,  they  may  become  more  rapid.  Sleep 
is  the  favorite  time  for  the  onset  of  asthmatic  seizures,  and  of 
croup,  true  and  false. 

It  is  always  advantageous,  when  it  is  possible  in  illness,  to 
estimate  the  pulse  and  respiratons  during  sleep,  that  the 
fallacies  which  are  apt  to  vitiate  the  observations  in  the  wak- 
ing state  may  be  avoided. 

Landois  and  Stirling  mention  that  the  elimination  of  car- 
bonic acid  is  diminished  one-fourth  during  sleep,  and  ascribe  it 
"to  the  constant  heat  of  the  surroundings  (bed),  darkness, 
absence  of  muscular  activity,  and  the  non-taking  of  food." 


Insomnia  and  its   Therapeutics.  o 

Pettenkoffer  and  Voit  stated  that  of  the  total  carbonic  acid 
eliminated  during1  twenty -four  hours,  58  per  cent  is  given  off 
during-  the  twelve  hours  of  the  day,  and  42  per  cent  during 
the  twelve  hours  of  the  night,  while  the  quantity  of  oxygen 
taken  in,  during  the  twelve  hours  of  the  night,  far  exceeds 
that  absorbed  during  the  twelve  hours  of  the  day. 

Temperature. — The  temperature  undergoes  modification 
during  sleep,  both  in  children  and  adults,  falling  from  0.5  to  2° 
Fahr. :  chiefly  for  two  or  three  hours  after  midnight.  It  falls 
similarly  during  the  day,  in  the  case  of  those  who  sleep  by  day 
and  work  by  night.  Helmholtz  states  that  a  man  weighing 
about  tAvelve  and  a  half  stone  gives  off  40  calories  of  heat 
every  hour  while  he  is  asleep,  and  112  calories  in  the  same  time 
when  he  is  awake. 

The  Secretions. — The  secretory  organs  are  less  active  dur- 
ing sleep.  The  conjunctiva!  secretion  and  nasal  mucus  are 
greatly  diminished  in  amount;  if  they  are  not,  as  in  conjunc- 
tivitis and  nasal  catarrh,  the  eyelids  are  gummed  together  in 
the  morning  and  the  nostrils  are  occluded  with  mucus.  The 
salivary  and  other  secretions  concerned  with  digestion  are 
only  formed  under  the  influence  of  suitable  stimuli,  and  these 
being  absent  during  sleep  they  are  not  secreted.  Absorption 
is  slowly  effected,  consequently  the  action  of  medicines  and 
poisons  is  retarded.  The  gastro-intestinal  movements  are 
either  wholly  in  abeyance  or  greatly  lessened. 

The  urine  is  secreted  in  smaller  quantitj',  the  amount  being 
about  a  fourth  of  that  secreted  when  awake;  and  the  urea 
formed  is  decreased  one-half  during  sleep. 

Mendel  found  that  urine  secreted  during  the  night  con- 
tained a  larger  quantity  of  phosphoric  acid  than  that  secreted 
and  passed  during  the  day,  showing  that  sleep  is  the  most 
favorable  time  for  the  nutrition  of  the  brain  tissue  and  the 
removal  of  its  waste  products. 

Bouchard,  writing  upon  the  toxicity  of  human  urine,  says 
that  the  urines  of  \vaking  and  sleeping  differ  not  only  in  in- 
tensit}',  but  also  in  quality ;  the  urines  of  sleep  being  always 
really  convulsants,  while  the  urines  of  waking  are  only  nar- 
cotics. 

The  secretion  of  milk  continues  during  sleep. 

Considerable  difference  of  opinion  exists  as  to  the  secretion 
of  sweat;  many  eminent  physiologists  holding  that  it  is  de- 


IO  Insomnia  and  its   Therapeutics. 

creased  during1  sleep  nearly  50  per  cent,  while  Sir  Dyce  Duck- 
worth and  others,  on  the  contrary,  believe  that  it  is  increased 
during  the  night,  on  account  of  the  greater  quantity  of  blood 
found  in  the  viscera  and  integument  at  that  time.  This  would 
well  explain  the  liability  to  ca'tch  cold  from  sleeping  in  a 
draught.  Sleep  is  the  chosen  time  for  the  profuse  sweats  of 
phthisis  and  frequently  also  of  rickets. 

THE  DEPTH  OF  SLEEP. 

The  depth  of  sleep  varies  considerably,  even  during  different 
periods  of  the  same  night.  It  may  be  so  light  that  conscious- 
ness is  only  momentarily  obscured  and  the  sleep  terminable 
by  the  slightest  external  disturbance ;  or  it  may  be  so  pro- 
found that  activity  in  all  the  cerebral  centres  is  suspended, 
and  only  the  strongest  external  stimulations  can  interrupt  it. 
External  excitations  acting  on  the  sensory  surfaces  and  cen- 
tres have  been  made  use  of  to  determine  the  depth  of  sleep. 
Kohlschiitter,  by  means  of  sounds  of  graduated  intensity, 
found  that  this  increased  very  quickly  at  first,  and  afterward 
more  slowly  until  the  end  of  the  first  hour,  when  it  reached  its 
maximum.  It  subsequently  decreased  quickly,  and  afterward 
more  slowly,  fluctuating  from  time  to  time  until  waking  oc- 
curred. Several  other  observers  have  made  experiments  on 
this  subject,  but  their  conclusions  do  not  differ  materially 
from  those  of  Kohlschiitter.  Attempts  have  also  been  made 
to  estimate  the  depth  of  sleep  by  the  modifications  which  the 
reflexes  undergo.  Rosenbach  found  that  in  the  first  period  of 
sleep,  when  it  was  yet  light,  there  was  weakening  of  the  re- 
flexes, and  contraction  of  the  pupils ;  in  the  deeper  sleep  which 
followed,  the  abdominal,  cremasteric,  and  tendon  reflexes  be- 
came abolished,  and  the  pupils  were  fully  contracted.  Dr. 
Lauder  Brunton  writes:  "  In  ordinary  sleep  reflexes  disappear 
in  the  same  order  as  in  chloroform  narcosis,  but  in  mesmeric 
sleep  the  reflexes  are  increased  as  in  narcosis  from  ether." 
He  also  writes :  "  According  to  Eulenberg,  in  chloroform  nar- 
cosis the  patellar  reflex  is  abolished  first,  then  reflex  from  the 
skin,  then  from  the  conjunctivas,  and  lastly  from  the  nose." 
"Narcosis  by  ether  differs  from  that  of  chloroform  in  the 
much  greater  increase  of  patellar  and  other  tendon  reflexes, 
both  in  extent  and  duration."  The  writer  can  confirm  these 


Insomnia  and  its   Therapeutics.  II 

observations,  excepting  that  which  refers  to  the  state  of 
mesmerism. 

THE  CAUSATION  OF  SLEEP. 

As  the  causation  of  sleep  from  the  earliest  times  has  been 
supposed  to  depend  in  some  manner  upon  alterations  in  the 
blood-supply  of  the  brain,  it  will  be  useful  to  consider  prelim- 
inarily some  points  in  connection  with  these  vascular  arrange- 
ments,  more  especially  as  the  cause  of  so  man}*-  forms  of  in- 
somnia is  to  be  found  in  some  interference  with  the  normal 
blood-supply,  either  as  regards  quantity  or  quality,  or  both 
combined. 

The  nutritive  arteries  of  the  brain  are  divisible  into  two 
sets,  the  central  and  the  cortical.  The  central  arteries  are 
vessels  coming-  off  from  the  main  arteries  near  their  origin  and 
supplying  the  basal  ganglia.  The  cortical  vessels  are  distri- 
buted to  the  gray  matter  on  the  surface  of  the  brain,  and  to 
the  underlying  subcortical  substance,  where  they  approach 
but  do  not  anastomose  with  the  central  nutritive  arteries. 
The  gray  matter  is  provided  with  a  rich  capillary  plexus  which 
brings  to  it  a  blood-supply  five  times  as  great  as  that  of  the 
white  substance.  All  these  arteries  are  terminal  vessels — 
that  is,  they  do  not  anastomose  one  with  another,  but  each 
supplies  independently  a  portion  of  the  cerebral  substance,  thus 
providing  for  the  simultaneous  vascularization  of  separate 
limited  areas  according  as  they  are  called  into  play  by  the 
association  of  ideas. 

During  activity  of  the  cerebral  centres,  the  blood-supply  of 
these  centres,  under  the  influence  of  the  vaso-motor  nerves,  is 
increased — the  increase  in  some  cases,  it  is  said,  being  from  30 
to  47  per  cent ;  on  the  other  hand,  when  activity  is  lessened 
the  blood-supply  decreases.  In  other  words,  the  blood-supply 
is  coincident  with,  and  in  ratio  to,  the  work  being  performed : 
ubi  irrita  tio,  ibi  affluxus. 

Many  have  doubted  the  possibility  of  increasing  or  dimin- 
ishing the  quantity  of  blood  in  the  brain.  The  second  Monro 
raised  the  question  as  to  whether  the  brain  could  be  congested 
at  all;  maintaining  that,  as  it  was  shut  up  in  a  closed  bony 
cavity  which  was  quite  filled  (i.e.,  with  no  vacuum),  it  could 
not  be  compressed.  This  led  to  the  inquiry,  Could  the  brain, 
be  depleted?  Upon  this  point  the  observations  of  Monro, 


12  Insomnia  and  its   Therapeutics. 

Kellie,  Bonders,-  Burrows,  Reid,  and  others,  are  well  worthy 
of  study.  There  is  no  longer  any  doubt  that  the  quantity  of 
blood  in  the  brain  varies  very  considerably  under  different 
circumstances,  and  that  its  distribution  can  be  modified  in 
divers  manners;  for  example,  the  capillaries  must  necessarily 
become  obstructed  when  the  veins  and  sinuses  are  engorged 
with  venous  blood. 

Variation  in  the  quantity  of  blood  in  the  cerebral  vessels 
is  made  possible  by  the  fact  that  the  brain  does  not  completely 
fill  its  bony  cavity,  part  of  the  space  being-  occupied  by  the 
ventricles  and  the  subarachnoid  and  perivascular  spaces 
which  contain  the  cerebro-spinal  fluid.  These  communicate 
freely  with  each  other  and  with  corresponding  structures  in 
the  spinal  canal,  so  that  when  the  brain  receives  an  increased 
amount  of  blood,  a  certain  quantity  of  cerebro-spinal  fluid  is 
displaced  and  compression  of  the  brain  avoided. 

Luys  went  so  far  as  to  believe  that  the  brain  changes  its 
position  in  the  different  postures  assumed  by  the  body. 

The  pressure  of  blood  in  the  brain  is  so  considerable  that 
it  causes  movements,  of  the  brain,  which  give  tracings  similar 
to  those  obtained  by  the  sphygmograph  from  direct  pressure 
over  arteries  in  other  parts  of  the  body. 

Meynert,  in  his  work  on  psychiatry,  discusses  fully  the 
movements  of  the  brain.  Briefly  stated,  they  are — Those  com- 
municated by  the  large  blood-vessels  at  the  base  of  the  brain, 
and  varying  from  sixty  to  eighty  in  the  minute  according  to 
the  pulsations  of  the  heart.  During  systole  of  the  vessels  the 
organ  is  thrust  upward  toward  the  vertex  and  inward  toward 
the  ventricles,  causing  displacement  of  lymphatic  fluid.  Those 
which  coincide  with  the  movements  of  respiration,  the  brain 
rising  with  expiration  and  failing  with  inspiration.  These 
movements,  numbering  fifteen  to  twenty  per  minute,  operate 
mainly  upon  the  sinuses,  and,  by  compressing  them,  drive 
along. the  venous  blood  toward  the  heart.  Those  connected 
with  the  vaso-motor  centre,  and  appearing  as  peristaltic 
movements  occurring  in  the  arteries  at  the  rate  of  two  to  six 
per  minute.  These  are  the  most  powerful  of  all  the  move- 
ments, and  more  pronounced  and  regular  during  sleep  than 
in  the  waking  state.  They  are  concerned  in  carrying  off  the 
waste  products  of  the  brain  by  establishing  currents  in  the 
lymphatic  fluids. 


Insomnia  and  its   Therapeutics.  13 

Professor  Mosso,  of  Turin,  conducted  upon  three  persons 
(in  each  of  whom  a  portion  of  the  skull  was  wanting,  permit- 
ting1 movements  of  the  brain  to  be  felt  through  the  scalp)  a 
series  of  experiments  connected  with  the  cerebral  circulation, 
particularly  during-  sleep.  By  means  of  special  instruments 
he  took  tracings  of  the  movements  of  the  brain  and  thoracic 
walls,  and  of  the  pulsations  of  the  heart,  and  of  the  radial 
artery  at  the  wrist.  He  further  devised  the  plethysmograph, 
by  mean  of  which  he  estimated  and  registered  the  quantity  of 
blood  in  the  forearm  and  hand.  And  he  showed  (1)  that  in 
the  act  of  going  to  sleep  a  dilatation  and  relaxation  of  the 
vessels  of  the  forearm  occur,  with  a  corresponding  contrac- 
tion in  the  vessels  of  the  brain,  this  change  becoming  most 
pronounced  during  deep  sleep.  (2)  That  all  external  stimula- 
tion, however  slight,  such  as  a  ray  of  light  falling  upon  the 
eye,  a  noise,  etc.,  is  attended  by  contraction  of  the  vessels  of 
the  forearm,  greater  blood-pressure,  and  an  increased  flow  of 
blood  to  the  brain.  (3)  That  these  changes  are  accompanied 
by  a  modification  of  the  respiratory  rhythm,  and  an  accelera- 
tion of  the  pulsation  of  the  heart.  (4)  That  during  sleep  the 
quantity  of  blood  in  the  brain  is  subject  to  fluctuation  without 
any  apparent  cause — these  fluctuations  in  the  blood-supply 
throwing  some  light  on  the  observations  of  Kohlschiitter  re- 
garding the  depth  of  sleep,  alluded  to  at  p.  508;  and  (5)  that 
all  mental  activity  is  attended  by  an  increased  quantity  of 
blood  in  the  brain. 

These  facts  abundantly  prove  that  the  functional  activity 
of  the  cerebral  cells  regulates  the  blood-supply  of  the  brain  in 
health,  and  that  it  plays  a  most  important  part  in  the  pro- 
duction of  sleeplessness. 

Until  recent  years  sleep  was  believed  to  depend  on  a  de- 
termination of  blood  to  the  brain,  on  account  of  its  supposed 
resemblance  to  coma,  a  condition  in  which  the  veins  and 
sinuses  are  engorged  with  blood,  the  nervous  centres  con- 
gested, and  the  activity  of  the  cerebral  cells  suspended.  These 
conditions  have,  however,  nothing  in  common;  sleep  being  a 
healthy  and  physiological  condition,  coma  an  unhealthy  and 
pathological  state,  though,  in  some  diseases,  the  one  glides 
imperceptibly  into  the  other.  Many  facts  have  been  adduced 
in  support  of  the  hypersemic  theory.  It  has  been  urged  that 
men  of  full  habit  of  body  and  prone  to  stoutness  are  usually 


14  Insomnia  and  its   Therapeutics. 

good  sleepers;  but  if  anything1  is  certain  in  medicine,  it  is  that 
hyperasmia  of  the  brain  is  incompatible  with  good  and  re- 
freshing- sleep  in  health ;  and  also  that  all  diseases  that  are 
accompanied  by  that  pathological  condition  are  invariably 
attended,  at  the  onset,  by  sleeplessness  and  restlessness.  Dr. 
Fox,  writing-  on.  insomnia,  mentions  that  Chapin  held  nitrite 
of  amyl  to  the  nostrils  of  sleeping-  people,  with  the  invariable 
result  of  awaking-  them  in  one  or  two  minutes;  while  it  has 
been  noticed  that  workers  in  the  manufacture  of  nitre-glyce- 
rin suffer  from  throbbing  carotids  and  sleeplessness;  and  every 
surgeon  who  has  tried  to  put  a  patient  under  chloroform  while 
he  was  asleep  can  testify  to  the  difficulty  of  doing  so  without 
awaking  him. 

The  belief,  however,  that  the  brain  was  congested  during 
sleep  prevailed,  in  spite  of  numerous  observations  (chiefly 
upon  the  movements  of  the  brain),  which,  so  far  from  tending 
to  support  the  hypothesis,  went  a  long  way  to  prove  that, 
during  sleep,  the  brain  contains  less  blood  than  when  awake. 
It  had  frequently  been  noticed  that  the  fontanelles  in  young 
children  fall  below  the  level  of  the  skull  during  sleep,  rising 
again  when  waking  occurs — a  fact  not  to  be  explained  on  the 
hyperaemic  theory. 

About  two  hundred  years  ago,  Philip  Verheyen,  the  Regius 
Professor  of  Surgery  in  the  University  of  Louvain,  propounded 
the  theory  in  his  work  on  anatomy,  that  sleep  was  due  to  the 
cessation  from  work  of  the  majority  of  the  external  senses, 
and  that  these  contained  certain  essences  (spiritus)  which 
passed  into  the  blood,  so  that  the  "greater  portion  of  the 
medullary  substance  subsides  or  contracts,"  and  that,  after 
sleep,  these  rush  back  into  the  brain  "  to  swell  it  up,  so  as  to 
cause  awaking" — and  further,  that  when  these  essences  did 
not  leave  the  brain,  dreams  resulted.  (Haller  and  Boerhaave 
adopted  the  hypothesis  of  animal  spirits,  supposing  that  these 
were  gradually  expended,  and  so  used  up  during  the  waking 
state,  and  that  they  were  restored  during  sleep.  The  former 
believed  that  the  passage  of  the  spirits  through  the  brain  was 
impeded  either  by  a  deficiency  or  immobility  of  the  spirits,  or 
by  compression  of  the  nerves.  The  latter  thought  sleep  due, 
either  to  the  obstruction  of  the  secretion,  or  to  an  altered  cir- 
culation of  the  nervous  spirits.  Cullen  compared  the  natural 
states  of  waking  and  sleeping  to  excitement  and  collapse,  a 


Insomnia  and  its   TJierapeutics,  15 

theory  which  pervaded  many  of  his  writings,  being-  known  as 
the  theory  of  excitement.  He  believed  that  the  quantity  of 
nervous  fluid  was  equable,  but  that  during-  waking-  it  moved 
with  greater,  and  during-  sleep  with  less,  vigor.  He  likewise 
thought  that  during  sleep  the  movements  in  the  brain  dimin- 
ished, and  that  a  degree  of  collapse  took  place ;  while  during 
waking  excitement  was  the  normal  and  necessary  condition.) 
This  statement  seems  to  be  wonderfully  near  the  truth,  though 
expressed  in  an  antiquated  phraseology. 

Blumenbach  ascribed  sleep  to  "  a  diminished  or  impeded 
flow  of  oxygenated  or  arterial  blood  to  the  brain."  In  1817 
he  recorded  the  case  of  a  young  man  under  his  care  whose 
skull  had  been  trepanned,  and  in  whom  the  brain  decreased 
in  size  during  sleep,  and  increased  when  he  awoke. 

Dr.  Hammond  noticed  that  the  same  thing  happened  in 
the  case  of  a  man  with  a  large  opening  in  the  skull,  the  result 
of  a  railway  accident;  and  he  devised  an  instrument  which 
demonstrated  and  measured  the  extent  of  the  cerebral  pres- 
sure. The  late  Dr.  C.  H.  Moore  wrote  that  the  same  "ob- 
servation was  made  in  Montpellier  a  century  ago  in  a  similar 
case,  and  it  was  noted  that  the  brain  rose  and  fell  in  propor- 
tion to  the  lightness  or  profoundness  of  sleep."  Many  distin- 
guished -surgeons  have  since  recorded  cases,  in  which  the  skull 
being  defective,  the  convolutions  of  the  brain  have  been  seen 
to  become  bloodless,  and  to  subside  below  the  level  of  the 
skull  during  sleep. 

These  observations  led  to  further  inquiries,  the  chief  of 
which  will  now  be  referred  to.  Donders,  in  1854,  performed 
some  experiments  on  a  dog,  trepanning  its  skull  and  substitut- 
ing for  the  bone  a  piece  of  glass,  when  he  found  that  during 
sleep  the  brain  became  anaemic.  Similar  experiments  were 
subsequently  carried  out  by  Ehrmann  in  an  improved  manner 
with  like  results,  and  these  have  since  been  frequently  con- 
firmed by  others. 

In  this  country,  Mr.  Durham,  in  the  "  Guy's  Hospital  Re- 
ports "  for  1860,  placed  upon  record  a  series  of  observations  he 
had  made  upon  dogs,  in  all  of  which  the  greatest  care  was 
taken  to  insure  accuracy.  Portions  of  the  skull  were  removed 
under  chloroform,  the  dura  mater  clipped  away,  and  pieces  of 
glass  secured  in  the  openings  by  means  of  Canada  balsam. 
He  noted  that  during  sleep  the  brain  became  pale  and  anaemic, 


1 6  Insomnia  and  its   Therapeutics. 

and  sank  below  the  level  of  the  skull,  the  amount  of  blood  in 
the  veins  being  reduced.  The  appearances  presented  by  the 
brain  during  its  periods  of  activity  differed  remarkably  from 
those  observed  during  sleep.  He  found  further,  that  on  in- 
ducing an  experimental  hyperaemia  of  the  brain  by  tying  the 
jugular  veins,  the  vessels  of  the  pia  mater  became  congested, 
while  the  animals  fell  into  a  state  of  torpor,  but  not  of  sleep. 
He  summarized  his  observations  in  the  following  deductions: 

"Pressure  of  distended  veins  upon  the  brain  is  not  the 
cause  of  sleep,  for  during  sleep  the  veins  are  not  distended; 
and  when  they  are,  symptoms  and  appearances  arise  which 
differ  from  those  which  characterize  sleep. 

"During  sleep  the  brain  is  in  a  comparatively  bloodless 
condition ;  and  the  blood  in  the  encephalic  vessels  is  not  only 
diminished  in  quantity,  but  moves  with  diminished  rapidity. 

"  The  condition  of  the  cerebral  circulation  during  sleep  is, 
from  physical  causes,  that  which  is  the  most  favorable  to  the 
nutrition  of  the  brain  tissue;  and,  on  the  other  hand,  the  con- 
dition which  prevails  during  waking  is  associated  with  mental 
activity,  because  it  is  that  which  is  most  favorable  to  oxida- 
tion of  the  brain  substance,  and  to  various  changes  in  its 
chemical  constitution. 

"  The  blood  which  is  derived  from  the  brain  during  sleep  is 
distributed  to  the  alimentary  and  excretory  organs. 

"  Whatever  increases  the  activity  of  the  cerebral  circula- 
tion tends  to  preserve  wakefulness;  and  whatever  decreases 
the  activity  of  the  cerebral  circulation,  and  at  the  same  time 
is  not  inconsistent  with  the  general  health  of  the  body,  tends 
to  induce  and  favor  sleep.  Such  circumstances  may  act  pri- 
marily through  the  nervous  or  through  the  vascular  system. 
Among  those  which  act  through  the  nervous  system  may  be 
instanced  the  presence  or  absence  of  impressions  upon  the 
senses,  and  the  presence  or  absence  of  exciting  ideas.  Among 
those  which  act  through  the  vascular  system  may  be  men- 
tioned unnaturally  or  naturally  increased  or  decreased  force 
or  frequeiiC3r  of  the  heart's  action. 

"A  probable  explanation  of  the  reason  why  quiescence  of 
the  brain  normally  follows  its  activity  is  suggested  by  the 
recognized  analogical  fact,  that  the  products  of  chemical 
action  interfere  with  the  continuance  of  the  action  by  which 
they  are  produced." 


Insomnia  and  its   TJierapentics  17 

In  18G6  Drs.  Hammond  and  Weir-Mitchell  conducted  a 
series  of  experiments  upon  dogs  under  the  influence  of  chloro- 
form and  opium  with  practically  the  same  results. 

It  seems,  therefore,  to  be  conclusively  demonstrated  that 
sleep  is  not  due  to  a  plethora  of  blood  in  the  brain. 

The  late  Dr.  C.  H.  Moore,  in  his  essay  on  the  "  Plrvsiology 
of  Sleep,"  ascribed  to  the  ganglionic  nerves  the  important 
function  of  constricting-  the  arterial  vessels  of  the  brain,  and 
so  inducing  an  anaemic  condition  which  temporarily  suspends 
cerebral  activity.  Support  was  gained  for  this  view  when  Dr. 
Flemming  showed,  by  experiments  upon  himself  and  others, 
that  a  state  resembling  sleep  could  be  immediately  produced 
by  compression  of  the  carotid  arteries.  It  was,  however, 
pointed  out  that  the  resulting  condition  was  one  of  syncope, 
and  not  of  sleep. 

Dr.  Cappie,  in  his  admirable  essay  on  the  "  Causation  of 
Sleep  " — a  work  well  worthy  of  perusal — states  that  among 
other  causes  there  is  an  increased  quantity  of  blood  in  the 
veins  of  the  pia  mater  which  exerts  a  certain  amount  of  press- 
ure on  the  gray  matter  of  the  brain;  adducing,  in  support  of 
this  opinion,  the  evidence  of  Dr.  Hughlings  Jackson,  who,  in 
ophthalmoscopic  observations  made  upon  sleeping  children, 
found  the  retinae  paler,  the  arteries  narrower,  and  the  veins 
more  dilated  than  during  the  waking  state.  He  also  cites  the 
statement  of  Dr.  Allan  Jamieson,  now  of  Edinburgh,  who  re- 
ported that  in  a  girl  in  a  state  of  trance  he  found  the  retinas 
pale,  the  arteries  small  and  hair-like,  and  the  veins  full  and 
large.  Such  evidence,  however,  loses  much  of  its  value  when 
the  appearances  are  found  to  be  inconstant.  Senator  has  re- 
corded that  the  ophthalmoscopic  appearances  were  normal 
in  a  case  of  prolonged  sleep  which  extended  over  some  months. 
Indeed,  it  is  extremely  doubtful  whether  ophthalmoscopic  ob- 
servations are  of  much  utilit}T  in  such  an  investigation;  for 
Dr.  Govvers,  in  his  work  on  "Medical  Ophthalmoscopy,"  in 
discussing  anaemia  and  hypersemia  of  the  brain,  writes:  "It 
has  been  supposed  that  the  state  of  the  circulation  in  the  eye 
and  brain  corresponds,  and  that  the  anaemia  and  hyperaemia 
of  the  brain  are  revealed  by  similar  conditions  in  the  fundus 
oculi.  But,  as  has  been  already  said,  such  a  statement,  if  true 
at  all,  is  true  only  within  certain  narrow  limits.  The  intra- 
ocular tension  so  regulates  the  state  of  the  vessels  of  the  eye, 


1 8  Insomnia  and  its   Therapeutics. 

that  very  little  alteration  occurs  in  them,  when  changes  occur 
in  the  condition  of  the  vessels  of  the  brain."  In  referring1  to 
cases  of  anaemia  Dr.  Gowers  says:  "It  is  possible  that  the 
initial  stage  of  an  epileptic  fit,  which  is  attended  by  pallor  of 
the  face,  may  be  accompanied  by  pallor  of  the  disc,  and  per- 
haps spasm  of  the  retinal  arteries;  but  very  little  evidence  of 
this  fact  has  at  present  been  obtained." 

Moreover,  it  must  be  borne  in  mind  that  the  very  fact  of 
examining  the  eye  is  sufficient  to  modify  the  circulatoiy  ar- 
rangements of  sleep.  It  has  been  already  stated  (p.  503)  that 
external  stimuli  of  all  kinds  induce  changes  in  the  pupil  in 
healthy  subjects;  and  it  has  also  been  shown  (p.  511)  that  they 
produce  alterations  in  the  circulation  of  the  brain ;  nay,  more, 
that  the  fact  of  throwing  a  light  on  the  closed  eye  is  sufficient 
of  itself  to  bring  about  these  modifications.  It  is  therefore 
evident  that  ophthalmoscopic  observations  made  during  sleep 
must  of  necessity  be  of  doubtful  value;  certainly  their  impor- 
tance falls  far  short  of  those  conducted  in  the  waking  state. 

Dr.  Cappie  takes  exception  to  Mr.  Durham's  conclusions, 
already  quoted,  alleging  that  atmospheric  pressure  would 
empty  the  veins  of  the  brain,  and  so  vitiate  the  results. 

Vulpian,  the  distinguished  physiologist,  adopted  the  same 
view,  believing  that  atmospheric  pressure  and  the  effects  of 
anesthetics  and  narcotics  are  important  factors  in  the  changes 
observed  in  the  experiments  of  Durham  and  Hammond.  He 
further  expresses  his  dissent  from  Dr.  Cappie's  proposition, 
on  the  ground  that  the  mere  displacement  of  blood  from  the 
arteries  to  the  veins  cannot  exert  pressure  on  the  nervous 
tissues. 

There  is  also  difficulty  in  accepting  Dr.  Cappie's  view  on 
the  further  ground  that  blood  in  the  veins  is  useless  for  nutri- 
tive purposes,  and  as  sleep  is  highly  restorative,  it  is  difficult 
to  conceive  how  depuration  and  recuperation  can  be  effected 
under  such  conditions.  Certainly,  passive  congestion  of  the 
brain  has  never  been  deemed  favorable  for  its  nutrition,  or  for 
sleep. 

Vulpian  holds  the  opinion  that  the  state  of  the  circulation 
of  the  brain  has  little  to  do  with  the  causation  of  sleep,  the 
vascular  and  cardiac  modifications  being  only  accessory  to  it. 
He  further  points  out  that  the  carotid  and  vertebral  arteries 
in  the  lower  animals  have  been  tied  so  as  to  cause  profound 


Insomnia  and  its   Therapeutics.  19 

anaemia  of  the  brain,  without  the  animals  being  made  appre- 
ciably drowsy. 

Professor  Mosso  demonstrated  that  in  the  act  of  awaking 
the  brain  undergoes  a  diminution  in  volume  and  contains  less 
blood  than  during  sleep;  this  would  appear  to  be  coincident 
with  the  sudden  dilatation  of  the  pupils  (p.  503).  Professor 
Mosso  thinks  that  this  shrinking  is  "  sufficient  to  render  un- 
tenable the  hypothesis  which  attributes  sleep  to  a  state  of 
anaemia  of  the  brain."  This  does  not  necessarily  follow.  Se- 
vere and  sudden  anaemia  is  productive  of  convulsions;  a  less 
intense  form,  of  sleeplessness  and  restlessness.  It  is  therefore 
suggested  as  probable  that  this  abrupt  depletion  may  be 
nature's  method  of  securing  awaking.  The  effects  which 
anaemia  produces  vary  very  greatly  in  different  cases,  and 
appear  to  depend  largely  upon  the  degree  of  the  anaemia  and 
the  mode  of  its  induction. 

Slight  and  gradual  anaemia  of  the  brain  is  conducive  to 
sleep.  There  is  abundant  evidence  to  prove  that  mental  iner- 
tia and  somnolence  manifest  themselves  when  the  brain  is 
gradually  deprived  of  its  normal  blood-supply.  Dr.  Buzzard 
has  recorded,  in  his  work  on  "  Diseases  of  the  Nervous  Sys- 
tem," instances  of  somnolence  in  cerebral  syphilis  lasting  sev- 
eral weeks,  which  he  states  were  probably  due  to  arterial  dis- 
ease, and  which  recovered  under  specific  treatment.  In  such 
cases  the  circulation  must  have  become  lessened  very  slowly, 
and  must  therefore  have  been  causative  of,  and  not  dependent 
on,  sleep. 

The  thyroid  gland  plays  an  important  part  in  the  regula- 
tion of  the  vascular  supply  of  the  brain,  preventing  too  great 
a  flow  to,  but,  particularly,  from  it.  The  extirpation  of  this 
gland  has  led  in  many  instances  to  mental  lethargy  and  som- 
nolence. 

Cases  of  "sleeping  sickness"  have  occurred  chiefly  in 
Western  Africa,  characterized  by  swelling  of  the  cervical 
glands  and  a  gradual  and  increasing  inclination  to  sleep.  The 
pathology  of  this  disease  is  not  known,  but  Dr.  Gore  recorded 
the  post-mortem  appearances  in  such  a  case  ("  British  Medical 
Journal,"  1875),  from  which  we  can  gather  that  the  brain  was 
abnormally  bloodless :  "  The  substance  of  the  brain  was  par- 
ticularly firm,  and  not  one  drop  of  blood  appeared  on  a  section 
of  any  part  of  it;  the  sinuses  were  unusually  deficient  in  the 


2Q  Insomnia  and  its   Therapeutics. 

quantity  of  blood."  Less  striking1  but  more  familiar  instances 
of  the  fact  that  a  moderate  depletion  of  the  brain  favors  sleep, 
are  to  be  seen  in  the  drowsiness  which  follows  the  partaking- 
of  a  full  meal,  and  after  a  hot  foot-bath. 

Some  have  suggested  that  the  quantity  of  blood  in  the 
brain  is  not  decreased  at  any  one  time  during-  sleep,  although 
the  total  amount  circulating-  throug-h  it  in  the  course  of  an 
hour  may  be  much  less  than  during  an  equal  period  in  the 
waking-  state,  thus  ascribing  the  causation  of  sleep  to  the 
slowing  of  the  pulsations  of  the  heart.  The  writer  is  satisfied 
this  is  not  the  explanation,  as  from  observations  he  has  made 
upon  persons  going-  to  sleep,  and  upon  those  drowsy  after 
meals,  he  has  ascertained  that  the  pulse  does  not  fall  very 
materially  until  sleep  ensues.  Indeed,  after  meals  the  pulse 
is  frequently  accelerated,  so  that  while  the  brain  is  deprived 
of  blood,  throug-h  contraction  of  its  vessels,  the  volume  sent 
is  transmitted  more  quickly.  Of  course  it  must  be  admitted 
that  the  very  fact  of  instituting  these  examinations  may  have 
disturbed  the  vascular  arrangements. 

From  these  remarks  it  seems  obvious  that  the  cause  of 
sleep  is  not  to  be  found  solely  in  the  cerebral  vascular  supply. 
There  is  much  truth  in  the  statement  of  Sir  J.  Crichton  Browne 
that  "  The  blood-vessels  were  clearly  made  for  the  brain,  and 
not  the  brain  for  the  blood-vessels;  and  the  amount  of  blood- 
supply  to  the  brain  and  its  several  parts  is  determined,  not 
by  vascular  domination,  but  by  the  functional  activity  of  the 
nervous  tissues."  Nevertheless,  the  vascularization  of  the 
brain  is  of  the  highest  importance,  and  in  connection  with 
sleeplessness  it  must  be  studied  most  narrowly. 

Waste  Products. — It  is  necessary,  before  going-  further,  to 
say  something  regarding-  waste  products,  seeing  that  they  have 
been  credited  with  sleep-producing-  properties.  J.  Ranke, 
many  years  ago,  pointed  out  that  muscle  is  weakened  by 
work;  and  that  by  the  exhaustion  of  its  store  of  oxyg-en,  and 
the  accumulation  in  it  of  the  products  of  disintegration  (chiefly 
lactic  acid  and  creatin),  it  loses  its  contractile  power  and  be- 
comes feeble  and  incapable  of  more  work.  During  rest  the 
agents  of  fatigue  are  removed,  the  oxyg-en  restored,  and  the 
muscle  once  more  becomes  capable  of  doing-  work.  In  proof 
of  this  he  showed  that  a  muscle  into  which  lactic  acid  is  in- 
jected becomes  enfeebled,  as  if  by  exercise,  and  requires  rest 


Insomnia  and  its   TJierapeutics.  21 

and  the  removal  of  the  noxious  agent  for  the  recovery  of  its 
normal  condition. 

Preyer,  applying-  the  same  reasoning-  to  the  nervous  sys- 
tem, attributed  sleep  to  the  using-  up  of  oxygen  and  the  ac- 
cumulation of  waste  products — ponogenes,  as  he  called  them 
— in  the  brain  and  nervous  S3rstem.  He  says:  "During-  an 
active  condition  of  mind  and  body,  certain  substances  are 
broug-ht  into  existence  which  are  not  found  (at  all  events  very 
sparingly)  during  a  state  cf  rest:  lactic  acid,  for  example, 
and  creatin.  These  latter  substances  may  accumulate  in  the 
blood,  and  as  they  have  a  great  affinity  for  oxygen,  they  ap- 
propriate a  principle  required  for  active  exertion.  The  first 
stage  of  this  accumulation  characterizes  fatigue,  the  second 
stag-e  gives  rise  to  sleep,  and  the  third,  when  oxidation  has 
been  completed,  is  followed  by  awaking/'  Preyer,  however, 
adds  that  the  artificial  introduction  of  lactic  acid,  or  of  the 
lactates,  into  the  system  has  not  always  been  followed  by 
sleep.  This  failure  of  the  lactates  to  produce  sleep  has  been 
noted  by  many  others.  According  to  Ehrlich  the  products  of 
cerebral  cell  activity  are  acid. 

"While  waste  products  may  be  a  factor,  sleep  is  not  to  be 
explained  on  such  grounds  solely:  they  do  not  account  for  the 
tendency  to  sleep  while  travelling  by  rail  in  hot  weather,  and 
other  similar  facts,  as  sleep  thus  induced  bears  no  relation  to 
the  amount  of  mental  work  done. 

Again,  idiots,  the  feeble-minded,  and  even  healthy  persons 
whose  brains  are  inactive,  sleep  much  longer  than  active- 
minded  men:  this  is  due  to  the  bloodless  condition  of  their 
brains,  and  not  to  their  need  for  recuperation.  Cases  have 
been  recorded  from  time  to  time  of  persons  sleeping  during 
several  days,  without  it  being  suggested  that  they  had  .made 
any  severe  calls  upon  their  intellectual  apparatus. 

Vital  Alkaloids. — Last  year  Professor  Leo  Erraro,  of 
Brussels,  in  an  elaborate  essay  founded  chiefly  upon  the  physio- 
logical work  of  Professor  Gautier  and  others,  raised  the  theory 
that  sleep  is  due  to  the  manufacture  in  the  body  of  vital  alka- 
loids— leucomaines — basing  his  arguments  mainly  upon  the 
fact  that  G.  Pouchhart  and  Bouchard  had  found  alkaloids  in 
human  urine  (p.  507),  and  that  Gautier  had  discovered  in  hu- 
man saliva,  alkaloids  which  were  venomous  or  narcotic,  at 
least  to  birds.  He  states  in  further  proof  of  his  theory  that 


22  Insomnia  and  its   Therapeutics. 

Gautier  has  Shown  that  creatin  leucomames  exert  a  power- 
ful influence  upon  the  nervous  centres,  producing"  drowsiness 
and  fatig-ue,  and  at  times  purging-  and  vomiting-.  Erraro 
compares  the  action  of  leucomames  to  that  of  narcotics  such 
as  morphine,  and  supports  the  comparison  by  stating  that 
"Beturk  and:  Van  Dissel  assure  me  that  of  forty-two  vege- 
table alkaloids  known  to  them,  only  morphine  partakes  with 
ptomaines  the  property  of  forming-  Prussian  blue,  by  the  re- 
duction of  the  perchloride  of  iron  and  of  the  ferricyanide,  and 
this  in  spite  of  the  presence  of  an  oxidant  as  energ-etic  as  an- 
hydrous chrome."  Leucomames  for  the  most  part,  according- 
to  Gautier,  resemble  ptomaines  in  being-  hig-hly  oxidizable. 
Morphine  is  also  easily  oxidized.  He  deduces  from  the  above 
data  that  muscular  and  cerebral  work  result  in  waste  of  the 
muscular  and  cerebral  tissues,  and  that  these  waste  products 
take  the  form  of  leucomames,  which,  by  accumulating-,  cause 
a  sensation  of  fatig-ue,,  and  intoxicate  the  superior  nervous 
centres  to  the  point  of  inaction,  which  is  equivalent  to  sleep. 
During-  sleep  these  products  are  slowly  oxidized,  and  when 
the  oxidation  is  completed  waking-  ensues. 

Dr.  A.  M.  Brown,  in  his  work  on  "Animal  Alkaloids,''  in 
discussing-  the  observations  of  Gautier  and  Bouchard  on  the 
toxic  qualities  of  the  human  saliva  and  urine  respectively, 
dwells  upon  the  toxic  narcotic  quality  of  the  saliva  and  urine 
eliminated  during-  the  day,  and  the  convulsive  quality  of  the 
urine  secreted  by  nig-ht.  He  refers  to  Houg-eney's  sug-g-estion 
that  the  nig-ht  saliva  of  man  may  also  be  convulsive,  and  adds : 
"It  would  certainly  be  remarkable,  if  true,  to  find  the  alkaloid, 
in  the  interrupted  succession  of  physiological  effects,  guaran- 
teeing, as  it  were,  the  alternation  of  sleep  and  wakefulness." 

The  Oxygen  Theory. — A.  von  Humboldt,  toward  the  end  of 
the  last  century,  propounded  the  idea  that  sleep  is  due  to  the 
want  of  oxyg-en;  and  Dr.  (now  Sir  Lyon)  Play  fair,  nearl}-  half 
a  century  ag-o,  pointed  out  that  everything-  which  robs  the 
brain  of  oxyg-en  conduces  to  sleep.  Since  then,  the  subject 
has  never  failed  to  receive  attention;  and  the  theory  advanced 
by  Humboldt  has  also  been  upheld  by  Sommer,  who  refers  in 
support  of  his  statements  to  the  observations  of  Pettenkoffer 
and  Voit  briefly  alluded  to  on  p.  507. 

This  is  well  exemplified  in  the  drowsiness  which  affects  a 
congregation  in  a  badly  ventilated  church.  (In  former  years, 


Insomnia  and  its   Therapeutics.  23 

when  less  attention  was  paid  to  the  renewal  of  the  air  in 
places  of  worship  than  is  customary  at  present,  the  pew- 
openers  were  armed  with  long  poles,  having*  a  fox's  tail  at- 
tached to  the  one  end,  to  tickle  the  faces  of  the  slumbering" 
females,  and  a  hard  knob  at  the  other  end,  to  awake  the 
sleeping-  males,  by  striking-  them  over  the  head !) 

Pfliigger  in  1875  showed  that  the  brain  is  extremely  sensi- 
tive to  the  want  of  oxygen  (thereby  confirming-  Dr.  Playfair's 
statement),  and  that  when  frogs  are  deprived  of  it  for  any 
length  of  time  they  gradually  fall  into  a  condition  resem- 
bling- sleep.  He  believed  that  the  activity  of  the  psychical 
cerebral  cells  depends  upon  the  quantity  of  intra-molecular 
oxygen  they  contain;  and  that,  in  the  gray  matter  particu- 
larly, all  function  is  attended  by  oscillating  or  explosive 
movements  in  the  cells,  these  movements  being  caused  by  the 
combination  of  the  oxygen  therein  contained  with  certain  car- 
bonaceous particles  in  the  tissues,  oxygen  disappearing  and 
carbonic  acid  being  formed.  If  these  movements  continue  to 
use  up  oxygen  at  a  greater  rate  of  speed  than  the  circulation 
can  replace,  a  time  comes  when  the  cerebral  cells  suffer  from 
the  want  of  oxygen  and  the  accumulation  of  carbonic  acid; 
the  explosive  movements,  meanwhile,  growing  more  and  more 
feeble,  and  psychical  operations  more  and  more  debilitated, 
until  eventually  sleep  ensues. 

In  this  connection  it  must  be  remembered  that  the  nervous 
tissues  derive  their  oxygen  from  the  blood,  and  that  when  the 
blood  is  deficient  in  oxygen-carrying  corpuscles,  these  textures 
suffer  to  the  same  extent  that  they  would  from  an  atmo- 
sphere defective  in  oxygen ;  and  being  semi-starved  they  grow 
irritable  and  hyper-sensitive. 

The  absence  of  external  stimuli,  such  as  exists  in  the  dark- 
ness and  quietness  of  the  night,  has  been  advanced  as  a  cause 
of  sleep,  and  not  without  reason.  Strumpell,  for  instance,  re- 
corded a  case  of  a  girl  of  sixteen  who  became  almost  entirely 
anaesthetic,  so  that  she  was  unable  to  perceive  the  most  vio- 
lent stimulation  of  the  skin  and  mucous  membranes,  while  the 
muscular  sense  and  even  the  sense  of  muscular  fatigue  were 
lost.  Relations  with  the  outer  world  were  preserved  by  two 
channels  only — the  right  eye  and  the  left  ear — and  if  the  eye 
was  bandaged  and  the  ear  plugged  she  fell  asleep  in  a  few 
minutes.  She  could  be  awakened  by  stimuli  acting  on  the 


24  Insomnia  and  its  TJicrapeutics. 

eye  or  ear,  but  if  left  alone  she  awoke  naturally,  in  response, 
apparently,  to  the  action  of  some  internal  stimulus. 

Periodicity. — Sleep  has  also  been  attributed  to  the  law  of 
periodicity  which  governs  all  natural  things.  In  the  vege- 
table world  these  periodic  changes  are  well  seen,  the  growth 
of  plants  being  more  rapid  during  the  night  than  during  the 
day,  while  the  leaves  of  many  of  them  assume  different  pos- 
tures during  the  alternating  periods  of  growth  and  rest,  as 
Linnaeus  first  pointed  out,  and  that  although  the  plants  are 
shut  up  in  a  room  from  which  all  light  is  excluded.  In  the 
animal  kingdom  the  same  periodicity  is  observed  as  regards 
rest  and  work,  and  this  holds  good  even  in  the  case  of  those 
centres  in  the  medulla  oblongata  which  apparently  never 
slumber — those,  namely,  which  preside  over  the  circulatory, 
respiratory,  alimentarj^,  and  other  systems.  There  is,  for  in- 
stance, a  period  of  rest  between  every  expiration  and  inspira- 
tion; the  gastro-intestinal  operations  are  carried  on  intermit- 
tingly;  while  the  heart  has  also  ample  time  for  rest.  Dr.  Yeo 
writes:  "If  we  assume  the  human  heart  to  beat  some  seventy 
times  a  minute,  each  cycle  would  occupy  about  eight-tenths 
of  a  second,  which  would  be  made  up  as  follows:  auricular 
systole  =  one-tenth  of  a  second,  ventricular  systole  =  three- 
tenths  of  a  second,  while  the  pause  (or  rest)  would  equal  four- 
tenths  of  a  second/'  This  rhythmic  repose  is  greater  during 
sleep,  when  the  heart  beats  more  slowly,  so  that  the  heart 
enjoys  nearly  twelve  hour's  rest  out  of  every  twenty-four.  In 
like  manner  the  nervous  system,  being  constantly  employed 
during  waking  hours,  requires  periodic  repose,  which  it  can 
only  obtain  during  sleep.  While  this  explains  the  need  for 
sleep,  it  throws  no  light  upon  its  causation. 

Sleep  by  Suggestion. — Considerable  attention  has  been 
paid  of  late  years  to  hypnotism,  and  many  observers  believe 
that  natural  sleep  is  due  to  self-hypnotism — that  a  man  sug- 
gests to  his  mind  "  sleep,"  goes  to  his  bedroom  for  the  express 
purpose  of  sleeping,  and  sleeps  by  "  suggestion."  Many  argu- 
ments are  advanced  to  support  this  view;  one  being  that  if  a 
man  wishes  to  rise  at  a  particular  hour  in  the  morning  he 
suggests  to  his  mind  before  falling  asleep  that  he  must  awake 
at  that  hour,  and  frequently  does  so. 

Dr.  Brown-Sequard  lately  propounded  a  theory  that  sleep 
is  due  to  an  inhibitory  act  in  the  nervous  system. 


Insomnia  and  its  Therapeutics.  25 

These  last  two  theories  appear  to  be  quite  untenable. 

Having-  now  stated  at  some  length  several  of  the  theories 
as  to  the  causation  of  sleep,  it  only  remains  to  reiterate  the 
remark  made  in  the  opening-  sentence,  that  no  one  of  them 
can  be  accepted  as  settling-  the  subtle  problem.  Whatever 
may  be  the  immediate  cause,  the  need  for  sleep  is  well  ex- 
plained by  the  fatigue  of  daily  toil,  in  which  waste  products 
are  manufactured  quickly  and  energy  is  expended,  and  that  a 
time  of  rest  is  required  for  the  removal  of  the  one  and  the  re- 
cuperation of  the  other. 

DREAMS. 

No  account  of  sleep  would  be  complete  which  did  not  em- 
brace the  subject  of  dreams;  for  it  is  only  by  reviewing-  the 
two  subjects  in  connection  with  each  other  that  any  compre- 
hensive acquaintance  with  either  can  be  gained. 

It  is  hig-hly  probable  that  all  animals  possessing-  brains 
dream.  Dog-s  and  other  animals  frequently  give  evidence  of 
this  in  their  sleep  by  noises  and  movements  which  testify  to 
activity  in  the  cerebral  centres.  Lucretius  believed  that  dog-s 
hunted  in  their  sleep.  That  their  dreams  are  not  always 
pleasant  is  indicated  by  their  awaking  suddenly  in  a  state  of 
agitation.  It  is  well  known  that  animals  suffer — like  the 
g-enus  homo — from  nightmare  and  somnambulism,  while  they 
can  be  readily  hypnotized. 

Dreams  are  manifestations  of  partial  or  disturbed  sleep, 
and  show  that  there  are  unequal  degrees  of  activity  in  the 
psychical  centres,  some  having-  abdicated  their  functions  in 
slumber,  while  others  are  in  varying-  degrees  of  activity. 
Those  which  are  asleep  no  longer  guide  and  rectify  the  work- 
ing of  those  which  are  awake  or  partially  awake.  It  seems 
likely  that  the  active  centres,  besides  being  divorced  from 
those  asleep,  enter  into  unusual  associations,  which  result  in 
distorted  functions — i.e.,  in  disjointed  and  absurd  aberrations 
of  thought.  During  waking  moments  thoughts  and  actions 
are  under  the  direction  of  the  will,  our  highest  faculties  being 
employed  to  guide  them.  Throughout  sleep  the  will  is  de- 
throned and  sensibility  suspended — that  being  the  essence  of 
sleep.  It  follows,  necessarily,  that  the  will  can  no  longer 
dominate  thought  and  movement;  and  if  we  recollect  that  the 
active  psychical  centres  are  uncontrolled  by  those  which  are 


26  Insomnia  and  its   TJicrapcutics. 

asleep,  while  their  activity  is  disorderly  and  their  operations 
are  badly  correlated,  we  can  well  understand  how  our  dreams 
run  on  without  rhyme  or  reason. 

It  has  been  suggested,  with  every  probability  of  truth,  that 
when  many  centres  are  active,  dreams  are  consistent  and 
coherent,  while  when  few  centres  are  working1  they  are  unreal 
and  extravagant;  stated  briefly,  the  difference  in  the  quality 
of  dreams  appears  to  depend  on  the  depth  of  sleep. 

Dreams  occur  most  frequently  at  the  commencement  and 
.termination  of  sleep,  the  inequality  in  the  state  of  the  cerebral 
centres  being  the  condition  necessary  and  suitable  for  their 
development.  They  are  of  importance  to  the  physician  in  in- 
dicating some  disturbance  in  the  economy  which  might  other- 
wise pass  unnoticed:  e.g.,  they  are  frequently  premonitory 
symptoms  of  apoplexy  and  phthisis  pulmonalis,  and  they  may 
be  excited  by  sensations  due  to  dyspepsia,  which  are  trans- 
mitted to  the  brain.  In  manj7  instances  dreams  bear  some 
relation  to  their  exciting  causes:  Maury's  observations  upon 
himself  in  reference  to  this  subject  are  well  worthy  of  study. 
Dreams  occasionally  exert  such  a  powerful  influence  upon  the 
mind  as  to  leave  permanent  impressions,  and  that  in  men  and 
wromen  of  the  strongest  intellect  and  the  greatest  courage — 
people  who  would  be  ashamed  to  confess  the  fact,  even  to 
themselves. 

Dream-laden  sleep  is  never  refreshing;  persons  who  dream 
much  rise  in  the  morning  as  tired  as  when  they  \vent  to  bed. 
The  brain  as  a  whole  is  not  rested  while  intellectual  operations 
continue,  and  its  hyperaemic  condition  is  unfavorable  for  its 
nutrition. 

Somnambulism,  or  sleep-walking,  occurs  when  the  centres 
of  consciousness  are  asleep,  the  motor  centres  being  awake  or 
active.  Uninhibited  by  certain  psychical  centres,  the  sleep- 
walker's muscular  sense  is  apparently  increased,  enabling  him 
to  walk  about  and  perform  feats  which  he  would  not,  in  his 
waking  moments,  undertake.  He  does  not  see,  hear,  or  smell; 
he  is  wrapt  up  in  the  dream  he  is  acting,  and  seldom  recollects 
that  he  has  walked  during  his  sleep.  To  this  subject  we  shall 
recur. 

Hypnotism. — Three  conditions  are  described :  the  lethargic, 
the  cataleptic,  and  the  somnambulistic,  the  latter  being  a 
state  of  artificial  somnambulism.  The  condition  has  been 


Insomnia  and  its   Therapeutics.  27 

recognized  from  the  earliest  ages.  Mesmer,  in  the  middle  of 
last  century,  gave  an  impetus  to  its  study ;  Mr.  Braid,  of  Man- 
chester, directed  much  attention  to  it  about  1843;  and  of  late 
years  it  has  been  extensively  studied  by  Charcot,  Liebault, 
Heidenheim,  and  others,  being  largely  used  on  the  Continent 
as  a  means  of  cure  by  "  suggestion."  Mr.  Braid  showed  that 
a  person  fixing  his  attention  steadfastly  upon  a  luminous  or 
dark  object  held  a  little  above  and  in  front  of  his  eyes,  so  as 
to  produce  a  convergent  and  superior  squint,  fell  into  a  deep 
sleep,  during  which  he  was  powerless  to  change  his  condition, 
except  at  the  instigation  of  the  operator.  It  is  necessary, 
however,  that  the  mind  should  be  concentrated  upon  the  ob- 
ject and  the  will  wholly  surrendered  to  the  influence  of  the 
operator.  Hypnotism  can  be  produced  in  many  other  ways, 
but  as  no  reference  will  be  made  to  it  as  a  means  of  treating 
insomnia,  it  is  not  necessary  to  consider  it  in  more  detail. 


CHAPTEE  II. 

GENERAL  REMARKS  ON  INSOMNIA. 

THE  word  "  insomnia/'  which  signifies  the  want  of  sleep,  is 
used,  popularly,  to  indicate  any  interference  with  the  depth 
or  duration  of  that  condition;  and  it  is  in  this  wide  sense  that 
the  word  will  be  used  in  these  pages. 

Insomnia  is  an  evidence  of  vigilance  in  the  cerebral  cells, 
initiated  and  maintained  by  some  perturbing  element  in  the 
system,  of  which  it  may  be  the  sole  symptom.  It  is  thus  de- 
signed to  subserve  a  highly  conservative  purpose.  In  some 
instances  it  attracts  attention  to  ailments  that  might  other- 
wise elude  detection ;  while  in  many  cases  it  is  a  necessity  for 
the  preservation  of  life,  as,  for  example,  in  some  diseases  of 
the  heart  and  lungs,  in  which  consciousness  is  required  for  the 
maintenance  of  respiration. 

It  is  not  a  disease,  but  a  symptom  of  many  diseases,  differ- 
ing widely  in  their  nature  and  complexity,  as  well  as  gravity. 
It  is  associated  equally  with  trivial  ailments  and  with  affec- 
tions which  jeopardize  life.  Its  severity  and  persistence  is  no 
guide  to  the  diagnosis  of  the  disturbance  upon  which  it  de- 
pends, for  in  such  important  lesions  as  organic  diseases  of  the 
brain  it  may  be  absent,  while  it  is  a  frequent  and  obstinate 
symptom  in  such  prevalent  affections  as  the  functional  de- 
rangements of  digestion.  Again,  diseases  which  are  wont  to 
give  rise  to  insomnia  cannot  be  said  to  do  so  uniformly  or 
constantly.  A  disease  may  produce  it  in  a  pronounced  form 
in  one  patient,  in  a  modified  degree  in  a  second,  and  not  at  all 
in  a  third;  and  it  may  originate  it  in  a  patient  at  one  time 
and  not  at  another.  The  wakefulness  appears  in  every  case 
to  be  influenced  and  biassed  by  the  condition  of  the  nervous 
system,  the  temperament  of  the  patient,  and  by  the  state  of 
the  general  health  at  the  time. 

In  many  severe  diseases,  e.g.,  typhus  fever,  sleeplessness 
per  se  endangers  life,  by  increasing  the  enfeeblement  and  ex- 


Insomnia  and  its   TJicrapcutics.  29 

haustion  at  a  critical  juncture,  when  a  refreshing-  and  quiet 
sleep  would  conserve  the  limited  store  of  strength  the  patient 
possesses.  In  cases  such  as  these  we  are  justified  in  ranking- 
sleep  as  a  powerful  curative  agent,  and  sufficient,  of  itself,  to 
determine  recovery. 

In  less  important  disorders  in  which  insomnia  is  an  un- 
yielding S3*mptom,  it  is  not  only  the  source  of  much  misery 
and  discomfort,  but  it  entails  upon  the  sufferer  a  grievous 
hardship,  in  that  he  has  to  fight  the  battle  of  life  in  a  maimed 
condition.  Deprived  of  the  nightly  restoration  of  his  potential 
energ3r,  his  brain  grows  weary,  and  his  whole  mental  and 
physical  vigor  becomes  impaired;  and  if,  in  these  circum- 
stances, he  persists  in  striving  to  work,  he  encroaches  upon 
his  fund  of  reserve  force  to  such  an  extent  as  to  lead  eventu- 
ally to  the  bankruptcy  of  his  nervous  system.  A  man's  power 
of  work  is  intimately  related  to  his  ability  to  sleep,  and  there 
is  no  more  reliable  indication  of  sound  health  than  the  capacity 
to  sleep  naturally. 

Sleep  has  been  called  "  Jbhe  chiefest  thing-  in  physic."  As  a 
restorative,  it  has  neither  substitute  nor  rival;  it  is  co-equal 
in  importance  with  food  and  clothing  for  the  preservation  of 
life. 

It  will  materially  assist  us  in  the  clinical  study  of  insomnia 
if  we  consider,  further,  certain  physiological  and  pathological 
facts  appertaining  to  sleep. 

First  of  all  we  may  predicate  that  sound  nervous  structures, 
'properly  nourished,  adequately  rested,  and  rightly  exercised, 
are  fundamental  desiderata  for  good  sleep;  and  on  the  other 
hand,  that  all  circumstances  interfering  with  the  health,  nu- 
trition, repose,  and  working  of  the  nervous  textures  are  detri- 
mental to  sleep.  Let  us  glance  very  shortly  at  these  points. 

found  Nervous  Structures. — These  comprise  typical  cells 
of  stable  character,  normal  nerve  fibres,  neuroglia,  blood- 
vessels, pericellular  and  perivascular  spaces,  etc.  We  pro- 
pose to  refer  to  the  first  two  essentials  only,  the  cells  and 
their  connecting  nerves,  as  the  remarks  regarding  them  will 
suffice  to  illustrate  the  fact  that  any  defect  in  one  or  more  of 
these  structures  must  of  necessity  disturb  the  harmonious 
working  of  the  others,  and  initiate  disordered  function;  while 
they  will  exemplify  the  truth  of  the  old  saying  that  "  a  chain 
is  no  stronger  than  its  weakest  link." 


30  Insomnia  and  its  Therapeutics. 

Cerebral  cells  vary  very  considerably  in  their  construction, 
size,  and  shape  according  to  the  special  functions  they  sub- 
serve. For  example,  some  possess  the  power  of  perceiving 
and  registering  impressions  transmitted  to  them,  and  others 
of  emitting  special  and  individual  impulses  which  they  have 
originated.  These  functions,  whether  psychical,  sensorj-,  or 
motor,  necessitate  a  faculty  for  storing  up  nervous  or  poten- 
tial energy  and  discharging  it  in  response  to  normal  stimuli 
— a  capacity  distinctly  characteristic  of  their  health. 

Cerebral  cells  differ  greatly  in  the  degree  of  stamina  they 
possess.  They  are  so  inherently  strong,  in  some  persons,  as 
to  be  able  to  resist  in  a  great  measure  the  effects  of  work  and 
strain;  while,  primarily  or  congenitally  feeble,  or  secondarily 
debilitated  by  unhealthy  conditions  in  others,  they  are  vul- 
nerable and  soon  break  down  under  the  wear  and  tear  of 
everj'-day  life.  They  display  their  enfeeblement  in  an  incom- 
petency  to  accumulate  nervous  force,  and  in  discharging  it  in 
response  to  trivial  excitations.  Such  cells,  in  short,  are  irri- 
table and  impressionable,  and  thus  liable  to  disturb  sleep. 

Some  cells  have  their  functions  so  perverted  by  imperfect 
nourishment  and  other  causes  that  they  originate  erroneous 
sensations  spontaneously;  for  example,  in  hypochondriasis. 

-  Unrest  in  the  cerebral  cells  is  perpetuated  by  faulty  condi- 
tions inherent  in  themselves;  by  sensations  combed  to  them,) 
whether  from  the  interior  or  exterior  of  the  economy ;  f  and 
an  altered  state  of  nutrition, (an  exciting  cause  whicH  will  b€ 
considered  in  detail  under  the  section  on  normal  metabolism. 

All  diseases  interfering  with  the  integrity  of  the  cells  are 
apt  to  lead  to  modifications  of  sleep.  When  organic,  they 
usually  cause  insomnia  in  the  early  stages;  in  the  later  there 
is  often  the  reverse  condition  of  coma.  When  functional,  as 
from  continued  psychical  operations,  they  are  invariably  at- 
tended by  insomnolenc3T. 

When  activity  is  excited  in  the  cells  by  perturbing  sensa- 
tions originating  in  distant  parts,  the  sensations  are  trans- 
mitted by  cells  at  the  distal  extremities  of  the  nerves  or  nerve 
endings,  cells  which  exist  in  every  portion  of  the  mucous  and 
cutaneous  surfaces,  as  well  as  in  the  deeper  structures,  and 
which  vary  in  size  and  shape  according  to  the  special  function 
that  they  subserve.  These  terminal  cells  transmit  different 
sensations  too  numerous  to  specify,  but  those  of  light,  sound, 


Insomnia  and  its   TJierapeutics.  31 

and  pain,  and  of  hunger  and  fatigue,  may  be  mentioned  to 
indicate  the  diversity  of  their  functions. 

Each  description  of  cell,  however,  practically  acts  in  a 
similar  manner,  receiving-  and  transmitting  its  own  particular 
kind  of  sensation  to  its  own  special  centre  in  the  brain.  For 
example,  the  terminal  endings  of  the  auditory  nerve  can  only 
receive  and  transmit  impressions  of  sound,  and  these  must 
reach  the  centre  for  hearing  before  they  can  be  recognized. 
All  conditions  (such  as  diseases  affecting  the  periphery,  organs, 
viscera,  etc.)  implicating  and  interfering  with  the  integrity  of 
these  terminal  cells,  render  them  irritable  and  liable  to  project 
impressions  arising  from  insignificant  causes. 

Nerve  fibres  of  varying  structure  connect  the  cerebral  and 
peripheral  cells.  For  their  efficient  function  they  are  depen- 
dent upon  the  integrity  of  the  cells  they  represent.  When 
the  cells  are  faulty,  the  nerves  participate  in  the  irritability, 
and  convey  trifling  impressions  in  an  amplified  manner.  This 
is  well  exemplified  in  the  exaggerated  reflexes  in  some  neuras- 
thenic conditions,  and  still  more  palpably  when  degeneration 
has  followed  destruction  of  the  cerebral  cells,  as  in  hemiplegia. 

In  health,  sensations  thus  conveyed  to  the  cerebral  cells 
arouse  activity  which  is  incompatible  with  sleep,  for  their  per- 
ception in  the  various  centres  in  the  brain  induces  in  them  a 
concurren/hyperaemia,  an  occurrence  to  which  we  must  revert 
at  some  length  immediately?} 

f  For  instance,  an  excess  of  light  in  a  bedroom,  such  as  pro- 
ceeds from  a  fire,  or  in /summer  from  the  early  morning  light, 
often  prevents  sleep.^/To  many,  complete  absence  of  light  is 
an  essential  condition  for  sleep.  It  is  recorded  that  Napoleon 
I.  (to  whose  sleeping  powers  reference  will  hereafter  be  made) 
could  only  fall  asleep  in  total  darkness. 

Noises,  too,  not  necessarily  loud,  but  out  of  place,  act  in 
like  manner  on  a  limited  number  of  persons.  One  constantly 
reads  in  the  newspapers  of  actions  being  brought  against  the 
owners  of  dogs  and  poultry,  by  people  whose  early  slumbers 
are  disturbed  by  barking  and  cock-crowing.  Certainly,  many 
persons  have  their  rest  disturbed  for  some  time  after  coming 
to  town  from  the  country,  and  others  cannot  sleep  with  a 
clock  ticking  in  their  bedroom. 

Smells  occasionally  hinder  sleep,  although  they  are  seldom 
capable  of  interrupting  it.  Of  the  power  of  smells  to  hinder 


32  Insomnia  and  its   Therapeutics. 

sleep,  the  writer  recently  had  practical  experience  while  trav- 
elling in  a  sleeping  carriage,  the  musty,  dusty  odor  of  the 
mattress  rendering  it  impossible. 

Pillows  of  hops,  wormwood,  mandrake,  henbane,  and  poppy 
capsules  were  used  in  olden  times  as  aids  to  sleep;  more  re- 
cently, those  composed  of  the  flowers  of  the  lime  tree  and  of 
the  leaves  of  the  blue  gum  tree  have  been  recommended. 
Neither  of  these  has  been  found  reliable,  the  writer  believes, 
because  their  odor  not  infrequently  prevents  sleep. 

Many  enfeebled  persons  are  extremely  sensitive  to  odors, 
and  are  apt  to  be  kept  awake  by  trifling  effluvia.  They  are 
equally  susceptible  to  insignificant  noises  and  other  sensory 
impressions  which  in  health  they  would  not  heed.  Their  com- 
plaint that  they  cannot  sleep  for  reasons  which  appear  to  be 
paltry  seems  to  be  well-grounded,  as  they  sometimes  get  to 
sleep  quickly  when  the  source  of  disturbance  is  removed. 

Taste  may  also  thwart  sleep.  For  example,  since  cascara 
sagrada  has  come  into  general  use  as  a  purgative,  many  pa- 
tients have  complained  that  its  taste  kept  them  from  sleeping. 

Painful  sensations  are  able  both  to  prevent  and  to  inter- 
rupt sleep.  It  is  practically  the  same  wherever  the  pain 
arises,  whether  central,  peripheral,  or  in  the  course  of  the 
nerves,  the  pain  being  referred  to  the  terminal  branches  of  the 
nerves.  Sensations  far  short  of  pain,  such  as  those  arising 
from  cold  feet,  and  from  the  irritation  of  eczema,  pruritus, 
etc.,  or  perverted  sensations,  as  formication,  are  all  able  to 
prevent  or,  if  already  induced,  to  terminate  sleep.  In  skin 
affections,  sleep,  good  or  bad,  is  intimately  associated  \vith 
improvement  or  the  reverse  in  the  progress  of  the  disease. 

Sleep  is  the  chosen  time  for  the  onset  of  many  painful  af- 
fections, such  as  the  passage  of  biliary  and  renal  calculi,  and 
many  diseases  having  "  algia  "  as  the  terminal  sj'llable  of  their 
names.  It  is  also  the  time  when  neuralgic,  syphilitic,  and 
other  pains  become  aggravated. 

Normal  Metabolism. — Insomnia,  from  whatever  source, 
is  so  constantly  associated  with  perverted  cerebral  vasculari- 
zation,  that  for  all  practical  purposes  we  may  conclude  that, 
primsfrily  or  secondarily,  it  is  excited  and  maintained  by  an 
alteration  either  as  regards  the  quality  or  the  quantity,  the 
access  or  the  egress,  of  the  nutritive  fluid. 

Healthy  cerebral  cells  require  for  their  recuperation  and 


Insomnia  and  its   Therapeutics,  33 

depuration  a  normal  blood-suppty.  They  are  extremely  sensi- 
tive to  all  interference  with  their  nourishment.  For  example, 
they  speedily  evince  the  effects  of  imperfectly  oxygenated 
blood  in  headache  and  drowsiness,  and  still  more  permanently 
the  consequences  of  an  impaired  metabolism  in  irritability  by 
day  and  sleeplessness  by  night.  In  the  course  of  this  work 
we  shall  require  to  consider  this  subject  fully  in  connection 
with  the  sleeplessness  which  occurs  in  the  various  fevers  and 
cachexise,  and  in  gout,  syphilis,  etc. 

Cells  inherently  weak  manifest  still  more  markedly  such 
defective  nutrition. 

It  will  be  advantageous  to  review  here  some  of  the  de- 
rangements which  are  apt  to  occur  in  the  circulation  of  the 
brain. 

Congestion  or  hyperaemia  of  the  brain  occurs  in  two  forms, 
active  and  passive.  The  first  is  accompanied  by  an  increased 
arterial  supply;  the  second  by  venous  stasis.  These  may  exist 
in  all  possible  degrees  and  in  very  varying  extent,  and  the 
congestion  may  be  slight  and  partial,  or  severe  and  general. 

Active  hyperaemia  may  occur  in  the  form  of  a  slight  and 
transient  congestion  of  a  very  limited  portion  of  the  cerebral 
tissue,  or  as  a  more  pronounced  general  congestion,  which  is 
the  first  stage  of  inflammation.  It  is  only  to  the  slighter 
cases  that  reference  will  be  made.  It  is  influenced  by  sex  and 
age.  Men  are  more  liable  to  cerebral  congestion  than  women 
and  children,  their  mental  and  bodily  activity  rendering  them 
so;  though  women  with  finely-developed  and  sensitive  nervous 
systems  are  frequently  the  victims  of  irritable  cerebral  cells, 
which  give  rise  to  hyperaemia.  Children  suffer  from  it  occa- 
sionally in  consequence  of  digestive  disorders,  and  also  during 
the  process  of  teething. 

It  is  most  frequently  seen  in  persons  of  sanguine  tempera- 
ment, who  have  a  tendency  to  vascular  derangements;  in  the 
plethoric,  with  their  florid  countenances,  short  necks,  and  ten- 
dency to  obesity;  and  in  those  who  have  a  well-marked  gouty 
diathesis. 

Mosso  found,  in  his  experiments,  that  all  mental  exertion 
and  emotional  excitement  were  accompanied,  in  health,  by 
functional  hyperaemia  of  the  brain.  This  is  quite  in  accordance 
with  the  law  that  the  blood-supply  of  an  organ  varies  with 
the  work  it  has  to  do. 


34  Insomnia  and  its  Tlierapeutics. 

It  occurs  as  the  result  of  all  diseases  which  increase  the 
force  and  frequency  of  the  heart's  action,  and  which  raise  the 
vascular  tension  unduly;  it  is  present  also  in  some  diseases  of 
the  blood-vessels;  chronic  alcoholism;  the  morphine  habit; 
organic  diseases  of  the  brain;  and  in  some  functional  derange- 
ments of  the  lungs,  liver,  and  gastro-intestinal  canal,  etc.,  etc. 

Passive  hyperaemia  exists,  like  the  active  form,  in  all  de- 
grees of  severity.  It  is  due  to  accumulation  of  blood  in  the 
veins  and  sinuses  of  the  brain,  a  condition  which  frequently 
gives  rise  to  coma.  The  blood,  impeded  in  its  return  to  the 
heart,  not  only  becomes  a  disturbing  element,  by  hindering 
the  capillary  circulation,  but,  venous  blood  being  unsuitable 
for  the  purposes  of  nutrition,  the  nervous  textures  are  starved, 
and  so  rendered  feeble  and  irritable.  The  causes  of  passive 
congestion  of  the  brain  are  chiefly  those  which  act  by  ob- 
structing the  free  return  of  blood  from  the  head,  such  as 
valvular  lesions  of  the  heart,  especially  if  the  right  ventricle 
is  dilated  and  the  lungs  and  other  organs  are  engorged; 
aneurisms  or  tumors  pressing  upon  the  veins  of  the  neck; 
severe  coughing,  particularly  whooping  cough;  bronchitis  and 
emphysema  of  the  lungs;  croup  and  laryngeal  diphtheria. 

Anaemia  of  the  brain  depends  upon  a  cerebral  blood-supply 
deficient  in  quantity  or  quality,  or  both  combined.  If  the 
quantity  is  greatly  reduced,  the  symptoms  to  which  the  im- 
poverished blood  gives  rise  are  aggravated  by  the  interference 
with  the  normal  pressure  within  the  skull.  Anaemia  may  be 
trivial  and  partial,  or  severe  and  general.  Among  the  causes 
are:  Hemorrhage,  as  in  accidents  or  operations;  uterine  hem- 
orrhages, post-partum  or  otherwise;  epistaxis;  haemoptj'sis, 
haematemesis;  hemorrhoidal  losses.  Exhausting  diseases,  es- 
pecially those  accompanied  by  profuse  discharges,  as  in  deep- 
seated  suppuration,  excessive  diarrhoea,  and  leucorrhoea;  con- 
tinued fevers;  septicaemia;  malarious  and  cachectic  conditions, 
and  wasting  complaints;  severe  inflammatory  diseases.  Af- 
fections interfering  with  the  calibre  of  the  cerebral  arteries, 
such  as  Bright's  disease;  syphilis,  aneurism,  or  tumor  obstruct- 
ing the  lumen  of  the  vessels,  and  complicated  sometimes  by 
passive  congestion;  embolic  and  thrombotic  obstructions. 
"Shock,"  caused,  for  example,  by  fright;  the  too  sudden  emp- 
tying of  the  pregnant  uterus  when  there  has  been  an  excessive 
accumulation  of  liquor  amnii;  the  sudden  evacuation  of  a  large 


Insomnia  and  its   Therapeutics,  35 

ovarian  cyst  or  of  a  collection  of  ascitic  fluid;  the  too  rapid 
emptying1  of  an  over-distended  bladder  in  certain  enfeebled 
states  of  the  system.  Heart  disease,  when  the  quantity  of 
blood  sent  to  the  brain  is  inadequate  in  amount,  as  in  some 
kinds  of  aortic  and  mitral  disease  and  in  fatty  degeneration. 
Poisonous  agents  in  the  system. 

We  must  now  inquire  into  several  subservient  agencies 
which  exert  a  very  decided  influence  upon  the  circulation  of 
the  brain  and,  consequently,  upon  sleep. 

Vascular  Tension. — This  was  alluded  to  in  enumerating 
the  causes  of  cerebral  hypersemia.  Its  modifications,  either 
in  the  way  of  increased  or  diminished  blood-pressure,  are  so 
invariably  associated  with  insomnia,  that  a  few  words  must 
be  said  regarding-  the  conditions  under  which  these  occur. 

The  blood-pressure  is  increased  when  the  calibre  of  the 
arterioles  is  narrowed,  and  that  whether  it  is  due  to  spasm  or 
to  organic  changes  in  the  walls  of  the  vessels  themselves.  In 
the  former  case,  it  may  depend  upon  stimulation  of  the  vaso- 
motor  centre,  as  in  great  emotional  excitement,  hysteria,  an- 
gina pectoris,  or  in  the  chills  which  mark  the  onset  of  acute 
diseases  and  the  cold  stag-e  of  the  intermit  tents.  It  may  like- 
wise result  from  the  presence  of  some  noxious  agent  in  the 
blood,  such  as  lead,  ergot  of  rye,  etc.,  or  the  materies  morbi  of 
g-out.  It  occurs  also,  in  all  cases,  where  the  heart  beats  with 
unusual  force  and  rapidity,  as  in  hypertrophy,  particularly  if 
it  is  associated  with  mental  excitement;  in  pregnancy,  in  ob- 
structive diseases  of  the  lungs,  such  as  bronchitis,  and  in  con- 
stipation of  the  bowels. 

Increased  arterial  tension  is  indicated  by  such  signs  as 
hard  and  incompressible  arteries;  accentuation  of  the  second 
sound  of  the  heart  best  heard  in  the  aortic  area,  and  prolonga- 
tion of  the  first  sound  most  marked  in  the  mitral  area;  and 
by  symptoms,  such  as  sleeplessness,  increased  micturition,  etc. 

Decreased  arterial  tension  depends  upon  the  reverse  condi- 
tions. It  occurs  when  the  arterioles  are  dilated,  as  in  all 
paralyzing  influences  acting  on  the  vaso-motor  centres,  such 
as  distressing  emotions;  in  weak  and  enfeebled  states  of  the 
system,  as  in  anaemia  or  phthisis  pulmonalis  and  cachexiae;  in 
the  course  of  most  of  the  continued  fevers;  and  very  markedly 
in  those  diseases  in  which  the  strength  is  drained  by  exhaust- 
ing discharges,  e.g.,  menorrhagia,  etc.  A  weak  heart  beating 


36  Insomnia  and  its   TJicrapcutics. 

slowly  and  feebly  is  constantly  associated  with  .low  tension. 
It  may  be  remembered,  however,  that  a  certain  amount  of  re- 
laxation of  the  blood-pressure  is  one  of  the  essential  factors 
in  producing  good  sleep.  The  signs  -of  decreased  vascular 
tension  are  soft  and  compressible  arteries;  enfeebled  cardiac 
sounds,  the  first  being  occasionally  inaudible,  etc. 

CARDIAC  AND  VASO-MOTOR  CENTRES  IN  THE  MEDULLA  OB- 

LONGATA. 

^Cardiac  Centres. — This  very  important  region  contains 
certain  nerve  centres  governing  the  heart,  by  means  of  which 
its  action  is  inhibited  or  accelerated,  these  being  in  the  most 
intimate  relation  with  the  whole  nervous  system.  Pleasur- 
able emotions,  for  example,  by  acting  upon  them,  cause  the 
heart  to  beat  more  vigorously;  while  sudden  fright  may, 
through  their  agency,  arrest  its  action.  Impressions  of  which 
\ve  are  unconscious,  transmitted  through  the  vagus  from  the 
gastro-intestinal  canal,  may  be  sufficiently  strong  to  cause 
inhibition  of  the  cardiac  action  and  intermission  of  the  pulse. 
Similar  sensations  may  be  conveyed  by  nerves  from  every 
part  of  the  body,  so  that  the  closest  and  most  sensitive  con- 
nections are  established  between  the  whole  organism  and  the 
heart.  Everything  which  tends  to  enfeeble  the  body  neces- 
sarily leads  to  disorderly  movements  of  the  heart,  which  are 
shown  by  its  halting,  irregular,  and  excited  pulsations. 

'aso-motor  Centres. — These  are  probably  in  close  proxim- 
ity to  the  cardiac  centres  in  the  medulla  (they  are  so  located 
in  the  rabbit).  By  means  of  the  nerves  with  which  they  are 
in  connection,  they  so  act  upon  the  muscular  walls  of  the 
arteries,  throughout  the  entire  body,  as  to  cause  dilatation 
and  contraction,  with  a  corresponding  increase  and  decrease 
in  the  amount  of  blood  that  they  contain.  These  vaso-motor 
centres  in  the  medulla,  which  are  the  dominating  centres,  and 
probably  made  up  of  constricting  and  dilating  mechanisms, 
are  supplemented  by  many  minor  centres  situated  in  as  many 
different  parts  of  the  gray  matter  of  the  spinal  cord.  Lanclois 
and  Stirling  state  that  "  From  the  vaso-motor  centre  fibres 
proceed  directly  through  some  of  the  cranial  nerves  to  their 
area  of  distribution;  through  the  trigeminus  partly  to  the 
interior  of  the  eye,  through  the  lingual  and  hypoglossal  to  the 


Insomnia  and  its  Therapeutics.  37 

ongue,  through  the  vagus  to  a  limited  extent  to  the  lungs, 
and  to  the  intestines."  .  .  .  "All  the  other  vaso-motor  nerves 
descend  in  the  lateral  columns  of  the  spinal  cord."  ..."  In 
their  course  through  the  cord,  these  fibres  form  connections 
with  the  subordinate  vaso-motor  centres  in  the  gray  matter 
of  the  cord,  and  then  leave  the  cord  either  directly  through 
the  anterior  roots  of  the  spinal  nerves  to  their  areas  of  dis- 
tribution, or  pass  through  the  rami  communicantes  into  the 
sympathetic,  and  from  them  reach  the  blood-vessels  to  which 
they  are  distributed."  It  follows  that  the  vaso-motor  centres 
are  in  the  most  delicate  and  intimate  relation  with  the  sensori- 
motor  nerves,  as  well  as  with  the  sympathetic  ganglionic  SA-S- 
tem,  and  are  so  sensitive  that  they  are  readily  affected  by 
alterations  in  the  quantity  and  quality  of  their  blood-supply. 
The  vaso-motor  nerves  are  probably  of  two  kinds.  One  variety 
has  the  function,  when  stimulated,  of  causing  contraction  of 
the  vessels  and  increased  blood-pressure — the  vaso-constric- 
tors;  the  other  has  the  power,  when  stimulated,  of  producing 
dilatation  of  the  vessels  and  diminished  blood-pressure — the 
so-dilators. 

The  centres  which  control  these  dilators  probably  act 
through  reflex  impressions.  When  the  vaso-constrictors  are 
inhibited,  the  arterial  vessels  dilate  and  the  blood-pressure  is 
lowered.  In  health,  the  vaso-motor  centres,  higher  and  lower, 
with  their  nerves,  co-ordinate,  in  order  to  preserve  in  all  the 
arteries  of  the  body  a  certain  amount  of  contraction,  known 
as  "  arterial  tone."  Interference  with  this  tonicity  may  be 
confined  to  limited  areas  or  it  may  become  general,  according 
to  the  nature  of  the  disturbing  influence;  but  whether  local 
general,  the  medullary  centres  dominate  the  whole. 

These  cardiac  and  vaso-motor  centres  are  intimately  asso- 
ciated in  the  medulla  oblongata  with  many  other  centres  of 
the  greatest  importance,  such  as  those  of  respiration,  mastica- 
tion, deglutition,  secretion  of  saliva,  vomiting,  sneezing,  and 
those  for  the  sweat  glands,  as  well  as  others  of  less  impor- 
tance. If  to  this  be  added  the  fact  that  all  the  cranial  nerves 
except  the  first  four  have  their  origin  in  the  medulla,  and  that 
all  sensory  and  motor  impulses  to  and  from  the  brain  pass 
through  it,  it  will  be  apparent  that  the  cardiac  and  vaso-motor 
centres  are  in  the  very  closest  proximity  to  centres  and  chan- 
nels which  control  and  communicate  with  every  part  of  th 


38  Insomnia  and  its   Therapeutics. 

body,  and  that  they  must  be  influenced  by  impressions  con- 
veyed to  them  by  contiguity  as  well  as  by  continuity.  Vomit- 
ing, for  instance,  is  of  frequent  occurrence  after  prolonged  fits 
of  coughing,  and  it  can  only  be  satisfactorily  explained  upon 
the  theory  that  the  excitement  in  the  centre  for  cough  spreads 
to  that  for  vomiting.  Sweating,  likewise,  is  caused  by  stimu- 
lation of  other  centres  in  the  vicinity  of  its  particular  centre ; 
e.g.,  many  persons  whose  sleep  is  disturbed  are  prone  to  wake 
bathed  in  cold  perspiration.  In  further  illustration  of  the  fact 
that  excitement  spreads  from  one  centre  to  another,  it  may  be 
mentioned  that  the  writer  has  twice  lately  witnessed  most 
profuse  sweating,  in  a  case  where  the  exciting  cause  was  a 
dyspeptic  attack  of  nervous  origin,  in  which  vomiting  and  op- 
pression of  breathing  were  marked  symptoms. 

Cough,  depending  upon  distant  excitations,  such  as  spinal 
irritation,  arises  in  a  similar-manner.  If  investigators  are 
able  in  the  future  toUemonstrate  the  existence  of  centres  for 
gout  and  other  constitutional  diseases,  which  are  at  present 
supposed  to  exist  in  the  medulla  oblongata,  in  close  proximity 
to  the  vaso-motor  centres,  it  will  be  easy  to  understand  why 
sleeplessness  is  so  apt  to  supervene  in  these  affections. 

'hat  mental  impressions  affect  the  vaso-motor  and  cardiac 
centres,  we  have  ample  evidence  in  the  pallor  induced  by  fear; 
while  we  know  that  stimulation  of  any  of  the  sensory  nerves 
leads  at  once  to  modification  of  blood-pressure,.  particularl3r 
in  that  of  the  brain.  It  has  been  suggested  that  this  is  the 
mechanism  by  which  the  safety  of  sleepers  is  secured.  Altera- 
tions in  the  quality  of  the  blood  lead  to  changes  in  the  cardiac 
and  vaso-motor  centres,  their  irritability  being  increased,  with 

\     consequent  contraction  of  the  arteries,  when  the  blood  is  cle- 

\  ficient  in  oxygen. 

xThe  sympathetic  or  ganglionic  nervous  system  exercises 
An  important  influence  upon  sleeplessness.    Dominating  as  it 

/  does  the  nutritive  processes,  and  acting  as  a  direct  channel  of 
communication  between  the  viscera  and  the  brain,  it  conveys 

\     impressions  arising  out  of  deranged  functions,  which  often 
lead  to  insomnia. 

It  does  not  seem  advisable  to  pursue  this  interesting  ques- 
tion a  greater  length,  sufficient  data  having  been  advanced  to 
indicate  its  bearing  upon  the  subject  under  consideration. 
The  diseases  enumerated  as  causes  of  active  and  passive 


Insomnia  and  its   Therapeutics.  39 

congestion  and  anaemia  of  the  brain,  as  well  as  the  conditions 
giving  rise  to  alterations  in  the  vascular  tension,  etc.,  will,  if 
carefully  scanned,  be  seen  to  correspond,  with  wonderful  ex- 
actness, to  a  list  of  the  diseases  which  give  rise  to  insomnia. 
It  is  not  for  a  moment  alleged  that  the  list  is  by  any  means 
complete,  or  that  insomnia  depends  solely  upon  these  vascular 
derangements,  brought  about,  in  some  cases,  by  the  influence 
of  the  brain  and  nervous  system;  'but  these  preliminary  con- 
siderations go  some  way  in  the  direction  of  a  rational  ex- 
planation of  the  causation  of  insomnia,  upon  which  we  may 
reasonably  hope  to  found  a  broad  and  enlarged  conception  of 
the  subject,  as  we  go  on  to  consider  in  detail  some  of  the  nu- 
merous diseases  of  which  it  is  a  symptom. 

Adequate  Repose.  —  In  the  preceding  chapter  we  saw 
that  repose  was  necessary  for  restoration  of  the  equilibrium 
in  the  nervous  system — for  the  removal  of  the  products  of 
waste,  and  the  renewal  of  nervous  energy. 

The  loss  of  a  single  night's  sleep  shows  its  effects  on  the 
nervous  system  in  the  exhaustion,  drowsiness,  irritability, 
febrile  disturbance,  and  digestive  derangements  which  ensue. 
The  tone  of  the  whole  body  is  lowered  to  such  a  degree,  as 
every  medical  man  knows  by  experience,  that  it  invariably 
requires  more  than  one  good  night's  sleep,  to  restore  the  in- 
dividual to  his  accustomed  mental  and  physical  state,  justify- 
ing the  old  saying  that  "  one  good  night's  sleep  requires  an- 
other." 

When  sleep  is  voluntarily  limited  for  any  length  of  time, 
the  consequences  are  perceived  in  a  still  more  marked  degree, 
and  may  be  well  studied  by  examiners  in  medicine  in  the  per- 
sons of  young  and  healthy  candidates,  who,  in  the  course  of 
preparation  for  examination,  have  made  continued  inroads 
upon  their  usual  allowance  of  sleep.  In  cases  such  as  these, 
the  system  becomes  exhausted,  and  they  look  worn  and  wan, 
feel  jaded,  depressed,  irritable,  and  disinclined  for  exertion. 
All  the  organs  suffer  from  enervation,  the  heart  becomes  irri- 
table, palpitates,  and  beats  intermittingly;  digestion  is  lan- 
guidly and  imperfectly  performed ;  and  if  the  pernicious  prac- 
tice has  been  carried  beyond  certain  limits,  disturbances  of 
nutrition  may  be  initiated  which  are  the  starting-point  of 
serious  organic  changes. 

These  effects  may  likewise  be  noticed  in  the  poor,  who  are 


40  Insomnia  and  its   Therapeutics. 

obliged  to  continue  their  work  into  the  night  to  eke  out  their 
means  of  subsistence,  as  well  as  in  searchers  after  pleasure 
who  convert  night  into  day.  The  results  in  the  former  case 
!/•  L^x^eing  complicated  by  symptoms  of  further  privations,  and  in 
both  by  the  breathing  of  heated  and  contaminated  air.  These 
consequences  appear  more  easily  and  quickly  in  those  whose 
nervous  systems  are  sensitive,  and  they  tend  to  develop  into 
diseases,  to  which  such  persons  may  have  an  hereditary  pre- 
disposition. A  time  at  last  arrives  when  sleep  can  no  longer 
be  obtained,  and  sleeplessness  becomes  the  bane  of  existence. 
This  S37mptom  being  superadded  to  the  already  enfeebled 
condition,  leads  to  neurasthenia,  or  to  diseases  more  grave, 
even  in  some  cases  to  insanity  and  suicide. 

In  animals,  the  untoward  effects  of  want  of  sleep  are  so 
generally  recognized  by  those  who  keep  them  for  gain  or 
work,  that  the  utmost  care  is  taken  to  secure  for  them  a  suffi- 
ciency of  undisturbed  sleep. 

Rightly-adjusted  Work. — As  in  a  subsequent  chapter  we 
must  discuss  this  subject  very  fully,  we  need  simply  premise 
here  that  a  function  can  only  be  satisfactorily  discharged, 
when  the  work  imposed  upon  the  structures  is  regulated  in 
accordance  with  their  strength.  It  is  equally  necessary  that 
the  tissues  should  be  exercised.  A  brain  which  is  properly 
used  is  adequately  nourished  and,  consequently,  vigorous.  Its 
functions  (such  as  sleep)  are  healthily  performed.  An  excess 
of  work  leads  to  hypersemia,  and  a  deficiency  to  anaemia,  of 
the  brain.  Both  of  these  conditions  are  unfavorable  for  good 
sleep. 

CONDITIONS  WHICH  INFLUENCE  SLEEP  AND  SLEEPLESSNESS. 

It  will  be  convenient  to  study  the  questions  of  sex,  age, 
temperament,  habit  of  sleep,  occupation,  method  of  living,  his- 
tory, season,  and  climate,  in  their  relation  to  sleep  and  sleep- 
lessness, the  amount  of  sleep  that  the  individual  requires 
being,  to  a  great  extent,  influenced  by  these  factors. 

Sex. — Men  require  less  sleep  than  women,  and  in  this  con- 
nection it  should  be  remembered  that  a  man's  pulse  beats  on 
an  average  five  times  less  per  minute  than  a  woman's.  As 
a  rule,  the  female  possesses  more  nervous  excitability,  and 
being  more  impressionable  than  the  male,  she  requires  more 
sleep  for  the  restoration  of  her  energies;  and  this  is  equally 


Insomnia  and  its   Therapeutics.  41 

true  of  the  weakly  and  of  convalescents,  in  whom  nutrition  is 
slowly  performed.  Women,  however,  bear  the  loss  of  sleep 
better,  for  a  time,  than  men.  The  length  of  time  they  can 
devote  themselves  to  night-nursing  in  response  to  the  calls  of 
affection  or  duty  has  scarcely  any  limit.  On  account  of  the 
impressionable  and  unstable  character  of  the  nervous  system, 
women  bear  the  strain  of  life  less  buoyantly  than  men,  and  so 
are  more  liable  to  insomnia.  Girls  more  frequently  than  boys 
suffer  from  overwork  at  school.  Woman's  work  in  every-day 
life  is  usually  more  monotonous  than  that  of  man ;  she  is  less 
in  the  open  air,  and  frequently  takes  less  exercise;  and  these 
causes  combined  are  not  conducive  to  good  sleep.  Men,  on 
the  other  hand,  have  to  bear  the  brunt  of  the  battle  of  life; 
this  in  many  instances  necessitates  great  mental  activity  and 
anxiety,  which  are  prone  to  cause  sleeplessness. 

Age. — A  large  portion  of  an  infant's  life  is  spent  in  sleep. 
The  enormous  expenditure  of  energy  connected  with  the  evo- 
lution of  the  brain  and  body  generally,  demands  a  relatively 
greater  amount  of  sleep  than  is  necessary  when  comparative 
maturity  has  been  reached.  Sleep  is  often  disturbed  at  this 
tender  age  by  improper  sleeping  arrangements,  as  when  the 
child's  feet  are  cold,  or  the  temperature  of  the  apartment  is 
too  high. 

The  need  for  sleep  decreases  as  the  growth  of  the  body  ap- 
proaches completion.  During  the  years  from  ten  to  twenty, 
from  nine  to  ten  hours'  sleep  are  required,  especially  on  the 
approach  of  puberty. 

In  middle  age,  when  the  waste  and  repair  of  the  tissues 
alone  require  adjustment,  eight  hours'  sleep  is  abundant. 

In  advanced  years,  the  bodily  temperature  is  modified,  the 
heart  beats  more  slowly,  the  cerebral  arteries  undergo  degen- 
erative changes,  brain  and  body  deteriorate,  and  nutrition  is 
slowly  and  imperfectly  accomplished.  Under  these  circum- 
stances a  longer  period  of  sleep  is  indispensable. 

The  late  Mr.  Hilton,  in  his  lectures  on  "  Rest  and  Pain," 
wrote :  "  The  interruption  of  rest  by  local  disease,  occurring 
to  persons  in  the  middle  period  of  life,  does  not  cause  the 
same  degree  of  exhaustion  and  wasting  as  in  the  young.  They 
bear  the  loss  of  sleep  better,  because  their  constitution  has  to 
sustain  the  stress  of  repair  only,  not  of  both  development  and 
repair,  as  in  the  child.  Their  recovery  is  slower;  their  subse- 


42  Insomnia  and  its  Therapeutics. 

quent  sleep  is  not  so  profound  nor  so  prolonged,  nor  their  rest 
so  complete.  The  defective  sleep  and  slow  repair  which  mani- 
fest themselves  in  the  old  after  injury  of  any  kind  are  familiar 
to  us  all." 

Notwithstanding-  the  general  indications  given  above,  it 
must  be  admitted  that  no  hard-and-fast  rule  can  be  laid  down 
as  to  how  many  hours  an  individual  ought  to  sleep.  For  all 
practical  purposes  the  rule  holds  good,  that  a  child  or  adult 
should  sleep  until  he  is  recruited,  awaking  in  the  morning  full 
of  vigor  and  with  a  marked  sense  of  well-being.  Restoration 
should  be  the  crucial  test.  It  is  a  far  more  reliable  guide 
than  any  empirical  statement  as  to  the  time  to  be  spent  in 
sleep;  for  it  follows,  if  it  is  wanting,  that  the  energies  have 
not  been  sufficiently  renovated.  Sleep  requires  to  be  of  cer- 
tain duration  and  quality  to  complete  the  repair  of  the  ex- 
hausted tissues  by  the  removal  of  the  excrementitious  products 
and  by  the  assimilation  of  the  pabulum  necessary  for  the  ac- 
cumulation of  the  store  of  potential  energy. 

No  two  persons  are  similarly  constituted,  and  if  they  were, 
the  demands  they  make  upon  their  strength  are  utterly  un- 
like. One  class  of  men  expend  their  energies  with  some  degree 
of  regularity;  while  another  class  make  extraordinary  calls 
upon  their  vigor  on  occasions  of  special  urgency.  This  latter 
class  is  illustrated  by  the  merchant  in  deciding  gigantic  trans- 
actions; by  the  barrister  in  important  trials;  and  by  the 
surgeon  in  deciding  upon  and  performing 'difficult  and  dan- 
gerous operations,  etc.  In  the  intervals,  no  such  expenditure 
of  energy  is  needed,  work  being  of  an  ordinary  and  less  event- 
ful kind.  Again,  the  demands  made  upon  the  digestive  sys- 
tem (not  to  refer  to  the  muscular  system)  vary  in  a  similar 
manner,  and  these,  implying  unequal  degrees  of  waste,  re- 
quire diverse  quantities  and  qualities  of  recuperation. 

The  benefits  arising  from  sleep  cannot  possibly  be  esti- 
mated by  its  duration  alone;  its  quality  is  an  equally  impor- 
tant factor.  There  are  many  kinds  of  sleep.  Without  referring 
to  restless  and  dream -laden  sleep,  it  is  a  matter  of  common 
knowledge  that  a  short  sound  sleep  often  recuperates  a  man 
better  than  a  long  sleep,  and  this  is  specially  the  case  in  par- 
ticular climates.  Many  bad  sleepers  find  themselves  much 
more  jaded  and  exhausted  after  an  unusually  long  and  very 
deep  sleep  than  after  one  shorter  and  less  sound.  Such  per- 


Insomnia  and  its  Therapeutics.  43 

sons  not  infrequently  awake  after  their  lethargic  slumbers 
bathed  in  perspiration  and  in  much  mental  distress. 

The  fickleness  (if  the  expression  may  be  permitted)  of  sleep 
is  well  exemplified  by  an  occurrence  which  almost  every  one 
must  have  experienced — that  the  invigoration  they  felt  on 
awaking  in  the  morning  after  six  hours'  sleep  was  completely 
dispelled  by  a  second  sleep  of  one  or  two  hours'  duration.  It 
is  equally  well  known  that  a  siesta  of  a  few  minutes'  duration 
is  often  followed  by  a  sense  of  invigoration,  while  one  lasting 
an  hour  or  two  is  followed  by  weariness  and  depression.  In 
this  latter  case  digestive  derangements  may  of  course  account 
for  some  of  the  depression. 

Temperament. — In  people  of  sanguine  temperament  the 
heart  is,  as  a  rule,  large  and  powerful,  the  circulation  active, 
and  the  bodily  functions  easily  and  quickly  performed;  so 
that  in  health  such  persons  usually  sleep  well  and  soundly, 
and  rise  in  the  morning  refreshed  and  vigorous.  About  mid- 
dle life  they  become  subject  to  circulatory  derangements, 
which  not  infrequently  lead  to  disturbed  sleep.  Many  in  this 
class  are  gouty,  and  consequently  have  a  predisposition  to 
insomnia,  depending  on  an  altered  state  of  the  blood  from  im- 
perfect metabolism.  Such  persons  bear  any  abridgment  of 
sleep  badly,  and  they  very  speedily  evince  signs  of  this  in 
general  enfeeblement.  They  suffer  more  quickly  and  severely 
from  loss  of  sleep  than  almost  any  other  class. 

The  neurotic  temperament  includes  a  class  whose  brain 
and  nervous  systems  dominate  tyrannically  over  the  other 
systems  of  the  body.  In  health,  sleep  is  of  comparatively 
short  duration.  Neurotics  are  indefatigable  workers,  prone 
to  fatigue  their  nervous  systems,  and  this,  combined  with  an 
hereditary  tendency  to  nervous  diseases,  conduces  to  bring 
about  conditions  which  cause  insomnia.  In  youth,  a  neurotic 
often  breaks  down  and  becomes  sleepless  from  mental  and 
physical  over-fatigue.  In  middle  age,  when  defective  innerva- 
tion  originates  faulty  digestion,  which  results  in  impaired  nu- 
trition of  the  brain  and  nervous  system,  sleeplessness  is  seldom 
absent. 

The  lymphatic  temperament  embraces  a  group  who  sleep 
well  if  not  soundly,  their  functions  being  languidly  performed. 
They  have  no  tendency  to  those  circulatory  or  neurotic  ail- 
ments which  are  pregnant  sources  of  insomnia. 


44  Insomnia  and  its   Therapeutics. 

There  are  many  combinations  of  these  temperaments,  and 
it  is  of  some  importance  to  trace  out  the  predominating  one, 
as  in  many  cases  it  affords  a  clue  to  the  origin  as  well  as  to 
the  treatment  of  persistent  wakefulness. 

Habit  of  Sleep. — Some  people  have  the  faculty  of  sleeping 
at  will,  and  certainly  the  power  may  be  cultivated,  as  it  is 
said  to  have  been  by  the  great  Napoleon,  M.  Thiers,  and  by 
the  first  Duke  of  Wellington. 

Others,  again,  have  accustomed  themselves  to  a  very  lim- 
ited amount  of  sleep,  and  are  able  to  work  actively  and 
steadily  for  lengthened  periods  of  time  without  suffering  any 
apparent  inconvenience,  while  sleeping  only  for  four  or  five 
hours  out  of  twenty-four.  As  a  rule,  however,  this  practice  is 
inadvisable,  for  though  all  duties  may  be  capable  of  easy  per- 
formance, there  is  a  liability,  in  such  persons,  to  the  onset  of 
certain  disorders,  and  probably,  in  the  long  run,  to  the  abridg- 
ment of  life.  John  Wesley,  who  appears  to  have  acquired  an 
excellent  habit  of  sleep,  believed  that  a  man  could  determine 
how  much  sleep  he  actually  needed  simply  by  rising  half  an 
hour  earlier  every  morning  until  he  fell  asleep  the  moment  he 
got  into  bed  at  night,  and  did  not  wake  until  it  was  time  to 
rise.  Such  an  opinion  must  be  accepted  conditionally;  the 
question  cannot  be  so  concisely  disposed  of.  It  is  recorded 
that  the  late  Duke1  of  Wellington  (who  had  a  famous  sleep 
habit)  said  to  some  one  who  remarked  that  his  bed  was  so 
narrow  that  there  was  no  room  in  it  to  turn,  that  "  when  a 
man  began  to  turn  it  was  time  to  get  up."  This  was  the 
speech  of  a  man  in  full  health  and  with  a  remarkable  faculty 
for  sleep.  Although  it  has  often  served  as  the  text  of  a  lec- 
ture on  the  subject  of  earty-rising,  it  has  no  general  applica- 
tion. Such  lectures  delivered,  as  they  commonly  are,  to  the 
indolent  and  slothful,  may  do  no  harm;  to  poor  sleepers  they 
are  nothing  less  than  travesties,  for  if  these  rose  every  time 
they  turned,  they  might  as  well  never  go  to  bed. 

Charles  Lamb,  in  his  famous  "  Essays  of  Elia,"  discusses 
several  popular  fallacies,  among  others,  "  That  we  should  rise 
with  the  lark/'  and  in  doing  so  states  the  other  side  of  this 
question.  "Not  but  there  are  pretty  sun-risings,  as  we  are 
told,  and  such  like  gawds,  abroad  in  the  world,  in  summer- 
time especially,  some  hours  before  what  we  have  assigned; 
which  a  gentleman  may  see,  as  they  say,  only  for  getting  up. 


Insomnia  and  its   Therapeutics.  45 

But  having  been  tempted  once  or  twice,  in  earlier  life,  to  assist 
at  those  ceremonies,  we  confess  our  curiosity  abated.  We 
are  no  longer  ambitious  of  being-  the  sun's  courtiers,  to  attend 
at  his  morning  levees.  We  hold  the  good  hours  of  the  dawn 
too  sacred  to  waste  them  upon  such  observances,  which  have 
in  them,  besides,  something  Pagan  and  Persic.  To  say  truth, 
we  never  anticipated  our  usual  hour,  or  got  up  with  the  sun 
(as  'tis  called)  to  go  a  journey,  or  upon  a  foolish  whole  day's 
pleasuring,  but  we  suffered  for  it  all  the  long  hours  after  in 
listlessness  and  headaches;  Nature  herself  sufficiently  declar- 
ing her  sense  of  our  presumption  in  aspiring  to  regulate  our 
frail  waking  courses  by  the  measure  of  that  celestial  and 
sleepless  traveller." 

The  benefits  accruing  from  a  capacity  to  fall  asleep  quickly 
and  to  slumber  soundly  until  the  hour  for  rising  cannot  be 
overstated.  Such  a  capacity  constitutes  a  good  habit  of  sleep. 
On  the  contrary,  the  practice  of  curtailing  sleep  by  sitting  up 
late  into  the  night,  or  by  rising  at  too  early  an  hour  in  the 
morning,  is  anything  but  a  desirable  one. 

Occupation. — The  more  highly-cultured  races  sleep  for  a 
shorter  time  than  those  in  the  lower  grades  of  civilization. 
Active  brain-workers  require,  and  probably  get,  a  smaller 
amount  of  sleep  than  those  who  are  engaged  in  manual  labor, 
and  still  less  than  those  who  spend  their  days  in  frivolity  and 
'  idleness.  They  live  their  lives  more  fully.  Some  of  the  most 
acute  and  brilliant  thinkers  and  writers  of  the  present  day 
sleep  comparatively  little,  from  the  power,  probably,  that  they 
possess  of  concentrating  their  sleep  (illustrating  the  quality 
of  sleep).  Brain -workers  are  peculiarly  liable  to  sleeplessness. 
The  cerebral  cells,  being  in  constant  use,  are  apt  to  remain 
active  after  wrork  has  been  abandoned,  and  while  this  is  the 
case,  sleep  is  prevented.  Those  who  work  with  their  bodies 
sleep  more  than  brain-workers,  for  two  reasons:  first,  on  ac- 
count of  the  resulting  physical  fatigue;  and  second,  because 
their  brains  being  seldom  called  into  activity,  hyperaemic  con- 
ditions which,  in  the  other  case,  act  as  causes  of  insomnia,  are 
absent.  Their  sleep  is  heavy  and  more  lethargic  than  in  the 
case  of  brain-workers.  If,  however,  the  work  is  carried  on  in 
close  workshops  and  in  constrained  positions,  the  dyspeptic 
troubles  which  are  liable  to  follow  may  induce  wakefulness. 
Dr.  Lauder  Brunton,  in  his  Croonian  Lectures  this  year,  re- 


46  Insomnia  and  its   Therapeutics. 

ferring1  to  'the  fabrication  of  lactic  acid  during  plv^sical  exer- 
tion, as  observed  by  Preyer  (page  519),  writes:  "If  much  of  it 
be  formed  in  consequence  of  violent  or  prolonged  exertion,  it 
will  pass  into  the  circulation  and  tend  to  lessen  the  alkalinity 
of  the  brain  as  well  as  other  tissues,  and  sleep  might  therefore 
be  induced  by  a  long  walk,  where  acid  is  formed  in  the  limbs, 
as  well  as  by  prolonged  mental  work,  where  the  acid  is  a 
product  of  the  brain  itself."  This  statement  makes  reference 
to  mental  and  physical  exercises  within  physiological  limits, 
for  no  fact  is  more  generally  recognized  than  that  mental  and 
bodily  over-fatigue  are  not  conducive  to  good  sleep.  A  certain 
amount  of  muscular  activity  is  almost  an  absolute  necessity 
for  sound  sleep.  (Exercise  is  the  antithesis  of  repose,  and  the 
study  of  every  function  indicates  the  need  for  work  alternating 
with  rest  for  its  healthy  performance.) 

It  may  be  that  a  limited  amount  of  lactic  acid,  such  as  is 
manufactured  by  an  adequate  measure  of  intellectual  and 
corporeal  work,  promotes  sleep;  while  an  excessive  formation 
of  acid,  the  result  of  exhaustive  labor,  hinders  sleep.  Such 
an  explanation  would  account  for  the  disturbed  sleep  in  acute 
rheumatism,  a  disease  in  which  an  acid,  probably  lactic,  is 
supposed  to  exist  in  excess  in  thje  blood.  Moreover,  it  would 
explain  why  gouty  persons  (whose  blood  contains  an  excep- 
tionally large  quantity  of  uric  acid)  are  so  much  troubled  with 
insomnia. 

Much  was  written  at  one  time  concerning  the  effects  of 
railway  travelling  in  preventing  sleep,  but  the  writer,  after 
careful  inquiries,  which,  as  medical  adviser  to  two  railwaj" 
companies,  he  had  extensive  opportunities  for  making,  was 
unable  to  find  any  evidence  in  support  of  this  opinion. 

Method  of  Living. — Large  and  generous  feeders  sleep  more 
than  small  and  careful  eaters,  the  continued  congestion  of  the 
digestive  organs  depleting  the  brain  and  favoring  sleep,  pro- 
vided no  dyspeptic  troubles  arise.  This  tendency  to  sleep  after 
meals  is  worthy  of  consideration  in  connection  with  the  hy- 
pothesis just  stated,  that  a  certain  increase  of  acid  in  the  blood 
tends  to  promote  sleep.  It  is  well  known  that  the  ingestion 
of  food  increases  the  alkalinity  of  the  blood.  Sir  William 
Eoberts  believes  that  a  meal  "  is  pro  tanto  a  dose  of  alkali, 
and  must  necessarily,  for  a  time,  add  to  the  alkalescence  of  the 
blood."  If  acid  was  an  essential  requisite  for  sleep,  it  would 


Insomnia  and  its   Therapeutics.  47 

almost  necessarily  follow  that  food  would  cause  wakefulness. 
Such  is  not  the  case.  The  belief  that  has  long-  prevailed,  which 
ascribes  drowsiness  after  meals  to  congestion  of  the  stomach 
and  a  concurrent  modified  anaemia  of  the  brain  appears  to  be 
well  grounded. 

Those  persons  whose  extremities  grow  cold  after  eating, 
the  kind  of  people  that  are  usually  subject  to  chilblains,  are 
frequently  poor  sleepers.  Those  who  consume  alcohol  in  any 
quantity  sleep  longer  and  more  heavily  than  those  who  ab- 
stain altogether.  Any  excess  requires  to  be  slept  off.  Both 
large  eaters  and  large  drinkers  are  prone  to  sleep  disturbance. 
Privation  leads  to  debilitated  conditions  which  are  inimical  to 
sleep.  Residence  in  unhealthy  places,  in  close  offices,  and 
badly-ventilated  rooms;  deficient  exercise;  excesses  of  all 
kinds;  the  inordinate  use  of  tea,  tobacco,  etc.,  are  all  sources 
of  sleeplessness. 

History. — This  embraces  hereditary  tendencies  to  nervous 
diseases,  such  as  insanity,  hysteria,  etc. ;  to  gout,  rheumatism, 
etc.;  to  heart  disease,  etc.,  which  are  all  predisposing  causes 
of  insomnia.  Evidence  of  'these  must  be  searched  for  in  the 
collateral  branches,  as  well  as  in  the  direct  line  of  descent.  It 
is  occasionally  useful,  when  consulted  by  a  sleepless  married 
person  of  middle  age,  to  inquire  carefully  into  the  health  of 
their  progenj",  for  a  history  of  somnambulism  or  incontinence 
of  urine  occurring  in  a  child  may  throw  a  good  deal  of  light 
on  the  case;  past  history,  as  previous  residence  in  unhealthy 
or  malarious  districts;  illnesses,  such  as  hemorrhages,  inflam- 
mations, fevers,  sunstroke,  syphilis,  dyspepsia,  etc.;  former 
habits — for  example,  excesses,  mental  or  physical  strain,  etc. ; 
present  condition — the  existence  of  obstructed  nostrils,  en- 
larged tonsils,  elongated  uvula,  and  like  abnormalities.  These 
and  similar  influences  are  provocative  of  sleep  disturbance. 
Persons  who  have  dry  and  harsh  skins  (skins  that  do  not  per- 
spire easily)  are  often  bad  sleepers. 

Season. — Less  sleep  is  demanded  in  summer  than  in  win- 
ter. This  has  been  attributed  to  the  fact  that  the  maintenance 
of  animal  heat  calls  forth  a  larger  consumption  of  energy 
during  cold  weather,  requiring,  in  consequence,  an  increased 
amount  of  sleep  to  adjust  the  equilibrium  between  waste  and 
repair. 

Climate. — For  a  like  reason,  those  who  reside  in  cold  re- 


48  Insomnia  and  its   Therapeutics. 

gions  require  more  sleep  than  the  inhabitants  of  warmer  cli- 
mates, the  temperate  zone  being  more  conducive  to  good  sleep 
than  those  localities  exposed  either  to  the  extremes  of  heat  or 
of  cold.  Cold,  by  contracting-  the  peripheral  vessels  of  the 
body,  causes  cerebral  congestion,  which  is  incompatible  with 
sleep.  If  the  cold  is  very  intense,  sleep  may  supervene,  but  it 
is  probable  in  this  case  that  the  sleep  is  associated  with  slight 
coma,  as  it  soo'n  deepens  into  that  condition,  and  is  followed 
by  death.  If  the  body  is  exposed  to  cold  during  sleep,  when 
the  bodily  functions  are  being  languidly  performed,  it  is  cooled 
with  greater  rapidity  than  if  it  were  exposed  to  the  same 
degree  of  cold  during  the  waking  state,  and  consequently  a 
fatal  termination  is  more  to  be  apprehended. 

Sleep  is  rendered  difficult  or  impossible,  also,  when  the 
temperature  of  the  atmosphere  is  high,  as  in  tropical  cli- 
mates; and  in  India  this  difficulty  is  so  generally  recognized, 
that  provisions  are  made  in  every-day  life  to  insure  sleep  be- 
moans of  artificial  devices,  those  who  can  afford  the  luxury 
securing  a  supply  of  cool  air  to  their  bedrooms  by  means  of  a 
punkah-wallah,  which  is  worked  by  a  servant  outside  the 
house.  Sir  Joseph  Fayrer  writes:  "Near  almost  every  vil- 
lage there  are  one  or  more  small  channels,  by  which  water 
from  the  neighboring  spring  is  conducted  to  the  cultivated 
lots  of  ground  for  the  purpose  of  irrigation,  and  these  chan- 
nels are,  in  parts,  formed  of  troughs  hollowed  out  of  trees.  A 
piece  of  bark  or  matting  is  laid  on  the  lower  of  these  troughs, 
and  on  this  the  infant,  swathed  in  a  large  mass  of  clothes,  is 
so  placed  that  the  water  from  the  upper  trough  falls  on  the 
vertex  of  the  cranium,  and  glancing  off  runs  away  under  the 
bark  or  matting,  without  further  wetting  the  child  or  its 
clothes ;  or  if  the  stream  is  full  and  copious,  the  child  is  placed 
on  the  side  of  the  channel,  and  a  portion  of  the  stream  directed 
on  its  head  by  a  large  leaf  or  piece  of  bark,  another  leaf  or 
piece  of  bark  being  arranged  on  the  other  side  of  the  head,  so 
as  to  catch  the  water  and  carry  it  away.  Children  so  placed 
will  lie  asleep  for  hours,  and  the  mothers  leave  them  while 
they  go  about  their  daily  occupations. 

Excessive  heat  has  a  marked  effect  in  producing  weak 
action  of  the  heart,  which  is  apt  to  be  followed  by  insolation. 
For  centuries  it  has  been  noted  that  unusual  dryness  of  the 
atmosphere,  such  as  is  found  on  the  shores  of  the  Mediterra- 


Insomnia  and  its  Therapeutics.  49 

nean,  is  a  frequent  cause  of  sleeplessness,  especially  in  excitable 
persons,  whose  sleep,  at  the  best  of  times,  is  not  satisfactory. 
It  is  important  to  bear  this  in  mind  when  recommending 
change  of  air  for  such  individuals.  Various  devices  have  been 
proposed  to  obviate  this,  such  as  hang-ing1  up  wet  sheets,  water- 
ing the  carpets,  or  exposing  vessels  of  water  in  the  room  to 
supply  the  deficiency  by  evaporation. 

One  constantly  hears  complaints  of  inability  to  sleep  dur- 
ing temporary  residence  at  seaside  resorts,  and  the  cause  of 
this  is  not  difficult  to  explain.  The  invigorating  air  acts  as  a 
powerful  tonic  to  the  heart  and  blood-vessels,  raising  the 
blood-pressure  considerably,  as  is  evidenced  by  the  large  in- 
crease in  the  amount  of  urine  secreted;  and  thus,  for  a  time 
at  all  events,  disturbing  the  balance  of  the  circulation  so  as  to 
interfere  with  sleep. 

Moderate  altitudes  are  more  conducive  to  good  sleep  than 
the  sea  level  or  high  altitudes. 

Many  persons  in  health  have  their  sleep  improved  by  a 
visit  to  the  seaside,  and  they  usually,  though  not  invariably, 
sleep  well  there  when  they  are  ill;  others,  again,  are  rendered 
wakeful,  and  this  is  generally  aggravated  during  illness. 

In  the  belief  that  it  may  serve  some  good  purpose  to  indi- 
cate the  causes  of  insomnia  as  they  present  themselves  to  the 
physician  in  private  practice,  the  writer  subjoins  a  list  of  one 
hundred  and  sixty-seven  consecutive  cases.  His  previous 
notes  are  of  selected  cases  alone.  From  the  category  are  ex- 
cluded all  cases  depending  upon  pain,  inflammatory  and  fe- 
brile affections,  cough,  as  well  as  the  more  trivial  cases,  caused 
by  drinking  tea  or  coffee  after  dinner,  in  which  the  insomnia 
disappeared  when  these  beverages  were  discarded. 

AGES. 
Cases.  Males.  Females. 

Neurasthenia,      .        .          19      48, 47,  44,  40,  40,  30,  45,  40,  34.  32,  30,  30. 

24,  19.  29,  28,  25,  25,  23. 

Chronic  gout,       .        .          19      74.  70,  61,  60,  56,  50,  84,  70,  65,  63,  60,  60, 

50,  44.  60,  59,  50,  45,  40. 

Overwork,    .        .        .          17      46,  45,  43.  42,  40,  40,  18,  13, 13, 11,  11, 10, 

30,  28,  18.  10,  10. 

Worry, ....          17      45,  45,  45,  44,  40.  66,  53,  46,  45,  45,  44, 

44,37,36,36,30,  22. 

Alcoholism,          .        .          10      55,  50,  50,  45,  36,  30.  60,  50,  49,  44. 

Dyspepsia  (not  gouty),         10      64.  40,  37,  34.  50,  46,  45,  34,  29,  26, 

Menopause,  ...            8  50,  49, 48, 46, 46,  46. 

45,  44. 

Senility,        ...            8      81,  77.  84,  81,  80,  76,  72, 63. 

Chronic  heart-disease,            6      61,  58.  76,  68,65,30. 


Insomnia  and  its  Therapeutics. 


Cases 

Males. 

AGES. 
Females. 

Incipient  Insanity, 

5 

70,  18. 

65,  63,  40. 

Night  terrors,      .        .  • 

5 

7,  4,  3. 

5,  3. 

Eczema, 

5 

68,  60,  54. 

45,  18. 

Rickets. 

4 

5,  3. 

4,2. 

Shock,  .... 

3 

80,  50. 

64. 

Exophthalmic  goitre, 

3 

42,  40,  24. 

Somnambulism,  . 

3 

30,  15. 

28. 

H  y  pochond  r  iasis," 

8 

45,  30. 

44. 

Paralysis  agitahs, 

2 

60,  54 

Migraine, 

2 

42,  31. 

Hysteria, 

2 

35,  20. 

Constipation, 

2 

34,  26. 

Syphilis  (acquired),     . 

2 

45. 

35. 

Syphilis  (inherited),    . 

1 

3  months. 

Epilepsy, 

1 

18. 

Locomotor  ataxy, 

1 

50. 

Enlarged  prostate, 

1 

85. 

After  parturition, 

1 

23. 

Noises,  .... 

1 

70. 

Post-choreal, 

1 

14. 

Anaemia, 

1 

30. 

Morphine  habit, 

1 

46. 

Chloral  and  cocaine  habit, 

1 

37. 

Tapeworm,  . 

1 

34. 

Threadworms, 

1 

50. 

Total, . 


167 


71 


Dr.  Guthrie  Rankin,  who  practises  in  the  county  town  of 
Warwick,  has  kindly  given  the  writer  his  notes  of  the  last 
sixty-three  consecutive  cases  of  insomnia — similar  to  the  above 
— that  he  has  had  under  his  care.  They  are  as  follows: 


Neurasthenia, 
Menopause, 
Chronic  gout, 
Worry,  . 
Overwork,    . 
Dyspepsia  (not  gouty), 
Post-dysenteric,  . 
Shock,  . 
Alcoholism,  . 
Anaemia, 
Senility, 

Chronic  heart  disease, 
Threatened  insanity, . 
Hyperosmia, 
Melancholia, 
Post-choreal, 
Since  childbirth, 
Somnambulism,  . 
Since  sunstroke,  . 
Chronic  bone  disease, 

Total,  . 


AGES. 
Cases.  Males.  Females. 

9  46.  54,  39,  39,  38,  32,  32,  32,  28. 

8  50,  50,  49,  49,  47,  46,  46,  40. 

7  53,38,32,32,32,26.  54. 

69,63,  56,  34. 

24,  22. 

40,  30. 

32. 

47,  38,  37. 

74. 

39. 

37. 

56. 
18. 
30. 

18. 


() 

54,  39. 

5 

33,  27,  17. 

4 

54,  47. 

3 

41,  28,  28. 

8 

76,  63. 

a 

45,  34,  31. 

3 

2 

84. 

2 

58. 

1 

1 

43. 

1 

1 

1 

1 

1 

28. 

1 

52. 


26 


37. 


Insomnia  and  its  Therapeutics.  51 

Dr.  Malcolm  Mackintosh,  who  practises  in  the  populous 
district  of  Clapham,  has  also  been  good  enough  to  furnish  the 
writer  with  notes  of  the  last  forty-three  consecutive  cases 
which  he  has  had  under  treatment. 

AGES. 


Males. 

Females. 

Worry, 

13      50,  44,  23. 

50,  50,  47, 

46,  45,  44.  39,  38,34, 

33. 

Neurasthenia, 

9 

53,  51,  48, 

48,  46,  42,  39,  37,  81. 

Chronic  bronchitis, 

4      72,  71,  43. 

56. 

Alcoholism, 

3 

60,  50  32. 

Dyspepsia. 

3 

56,  48,  36. 

Chronic  phthisis, 

2 

48,  42. 

Menopause, 

2 

49,  46. 

Senility,  . 

2 

82,  72. 

Chronic  rheumatism, 

2      53,  48. 

Disease  of  stomach, 

1 

41. 

Epilepsy, 

1 

42. 

Chronic  uterine  disease 

1 

32. 

Total,     ...    43  8  35 

Although  no  definite  or  reliable  conclusions  can  be  deduced 
from  such  scanty  premises,  these  statistics  are  nevertheless 
valuable,  as  indicating,  in  some  measure,  the  causes  of  func- 
tional (?)  insomnia,  and  the  ages  at  which  these  most  frequently 
operate.  Being  consecutive  cases,  and  occurring  in  different 
parts  of  the  country  and  in  varying  classes  of  society,  they 
show  the  influence  of  like  agencies,  and  that  these  act  with 
tolerable  uniformity. 

They  justify  the  opinion  which  the  writer  has  long  held, 
that  quite  a  half  of  all  of  the  cases  that  are  popularly  known 
as  functional  insomnia  are  due  to  an  inherent  instability  in 
the  cerebral  textures  which  renders  them  vulnerable,  and  lia- 
ble to  be  impressed  unfavorably  by  circumstances  incident  to 
various  stages  of  life;  in  short,  prone  to  break  down  under 
the  strain  of  the  wear  and  tear  of  every-day  life. 

In  the  writer's  own  cases  such  defective  structures  may 
be  said  to  have  caused  the  following.  Neurasthenia  19,  over- 
work 17,  worry  17,  menopause  8,  night  terrors  5,  shock  3,  hy- 
pochondriasis  3,  somnambulism  3,  hysteria  2,  epilepsy  1,  in- 
cipient insanity  5,  post-choreal  1,  after  parturition  1,  migraine 
2;  in  all,  87  cases,  or  52.095  per  cent. 

The  other  cases  are  as  follows : 

Gout,  or  defective  metabolism,   .    19  cases,  or  11.372  per  cent. 
Toxic,  alcohol,  etc.,       '.        .        .15        «  8.982       " 

Alimentary  system,      .        .        .14        "          8.383       " 


52  Insomnia  and  its   Therapeutics. 

Circulatory  system,      .        .        .10  cases,  or  5.987  per  cent. 

Senility,          .        .        ,        .        .      8        "  4.790 

Cutaneous,    .        .        v    J  ^       .5        "  2.994 

Rickets,          .        .        .      -v       .       4        "  2.335 
Paralysis  agitans  and  locomo- 

tor  ataxy,               ,        .        .      3        "  1.796       " 

Enlarged  prostate,       .        .        .1        "  .598       " 

Noises,    .        .        .        .        ...    1        "  .598        " 


Total,        .        .  167  99.930        " 

The  combined  statistics  of  two  hundred  and  seventy-three 
cases  of  insomnia  were  caused  mainly  by — 

(1)  Neurasthenia,  .    37  cases,  or  13.55  per  cent. 

(2)  Worry,          .  ^ .     35  "  13.18 

(3)  Gout,    .         .  *.     26  "  9.52 

(4)  Overwork,    .  ..23  "  8.04        " 

(5)  Menopause,  .  .18  "  6.59        " 

(6)  Dyspepsia,    .  .17  "  6.22        " 

(7)  Alcoholism,  .     16  "  5.86 

(8)  Senility,        .  .12  "  4.39 

In  short,  these  eight  causes  account  for  184  cases,  or  67.36  per 
cent  of  the  whole  number.  They  will,  consequently,  form  the 
chief  subjects  for  discussion  in  the  following  pages. 

These  statistics,  moreover,  when  considered  in  connection 
with  previous  experience,  go  some  \vay  in  the  direction  of  con- 
stituting a  basis  upon  which  the  sources  of  insomnia  may  be 
generally,  if  roughly,  summarized  as  follows: 

In  the  tender  age  of  infancy,  digestive  derangements  (which 
often  arise  from  injudicious  feeding);  dentition;  hereditary 
taint,  as  syphilis,  and  rickets,  act  prejudicially;  and  infantile 
convulsions,  night  terrors,  laryngismus  stridulus,  spasmodic 
croup,  etc.,  are  the  result. 

In  childhood,  while  yet  the  emotional  centres  predominate 
in  activity,  impressions  such  as  fright,  fear,  etc.,  cause  chorea ; 
and  these,  as  well  as  digestive  derangements  and  the  strain 
of  educational  competition,  lead  to  impaired  sleep.  At  this 
period,  sleep  is  apt  to  be  unequal  in  distribution  and  depth,  a 
condition  which  initiates  somnambulism,  incontinence  of  urine, 
and  similar  disorders. 

At  puberty,  when  the  evolution  disturbs  the  equilibrium 


Insomnia  and  its   Therapeutics. 


53 


of  the  nervous  .system  in  girls,  hysteria,  epilepsy,  and  like  ail- 
ments may  be  induced,  and  result  in  insomnia.  At  this  age, 
boys  and  girls  may  suffer  from  the  effects  of  overwork. 

TABLE  INDICATING  THE  AGES  AT  WHICH  INSOMNIA  OCCURS. 


Dr.  Macfarlane's 

Dr.  Rankin's. 

Dr.  Mackintosh's 

Totals. 

1 

Females. 

•a 
g 

tf 

1 

1 

1 

1 

Females. 

3 

i 

1 

i 

I 

10 
18 

1  —  10  years 
10—20    " 

5 
6 

5 
9 

10 
15 

5 

7 

5 

11. 

1 

2 

3 

20—30     " 

3 

12 

15 

3 

5 

8 

1 

•  i 

7 

17 

24 

30—40     tl 

9 

17 

26 

9 

13 

22 

10 

10 

18 

40 

58 

40—50     " 

22 

26 

48 

6 

10 

16 

3 

15 

18 

31 

51 

82 

50—60     " 

12 

5 

17 

4 

4 

8 

2 

7 

9 

18 

16 

34 

60—70     " 

7 

13 

20 

1 

2 

3 

1 

1 

8 

16 

24 

70—80     " 

4 

5 

9 

1 

1 

2 

2 

1 

3 

7 

7 

14 

80—90     " 

3 

4 

7 

1 

1 

1 

1 

4 

5 

9 

273 

Total 

71 

96 

167 

26 

37 

63 

8 

35 

43 

105 

168 

In  adult  life,  sleeplessness  is  apt  to  appear  at  an  earlier 
age  in  women  than  in  men.  This  arises,  in  the  married,  from 
disturbance  of  the  uterine  functions,  pregnancies,  hemor- 
rhages, and  over-lactation.  In  the  childless,  from  causes  con- 
nected with  their  sterility.  In  the  unmarried,  from  disap- 
pointments, etc.  In  all  these  cases,  the  indiscreet  use  of  tea 
and,  in  rarer  instances,  of  alcohol,  may  act  deleteriously;  while 
many  such  persons  tend  to  become  neurasthenic. 

In  middle  ag-e  there  are  three  great  sources  of  sleeplessness 
in  men:  neurasthenia;  metabolic  and  digestive  derangements; 
poisons,  as  tea,  tobacco,  and  alcohol.  In  women  the  sources 
are  chiefly  threefold :  neurasthenia,  the  menopause,  lithiasis. 

In  later  life,  when  the  trials  of  existence  begin  to  press 
heavily  and  to  be  borne  less  buoyantly,  worry  becomes  a 
pregnant  source  of  insomnia. 

In  advanced  years,  an  altered  state  of  the  nutrition  of  the 


54  Insomnia  and  its   Therapeutics, 

brain,  and  digestive  and  circulatory  troubles,  are  the  chief 
causes  of  disturbed  sleep. 

Diagnosis. — As  insomnia  depends  on  causes  so  numerous, 
so  diverse,  and  so  inconstant,  it  is  impossible  to  generalize  or 
to  formulate  a  table  to  convey  any  clear  idea  of  its  source. 

Every  case  requires  to  be  studied  carefully  upon  its  own 
merits,  but  the  main  lines  upon  which  the  inquiry  should  be 
conducted  may  be  briefly  indicated.  The  age,  sex,  and  occu- 
pation of  the  patient  should  be  noted,  and  the  habits,  past  his- 
tory, temperament,  and  hereditary  tendencies  investigated, 
especial  attention  being  directed  to  the  habit  of  sleep.  In  ob- 
scure cases,  the  condition  of  the  nervous  system  should  be 
studied  in  order  to  determine  whether  the  excitability  of  the 
cerebral  cells  is  dependent  on  inherent  exhaustion  or  on  irrita- 
bility, or  is  due  to  impressions  transmitted  from  distant  parts 
of  the  body.  The  state  of  the  various  reflexes,  and  the  con- 
ductivity of  the  nerves,  especially  the  cranial  nerves,  should 
be  ascertained.  The  condition  of  the  digestive  organs  and 
liver  must  be  narrowly  scrutinized.  Careful  examination  of 
the  vascular  system  should  be  made,  and  the  amount  of  vas- 
cular tension  determined;  and  any  modification  in  the  quan- 
tity or  quality  of  the  blood  noted,  such  as  anaemia,  or  plethora, 
or  the  presence  of  the  gouty,  rheumatic,  or  S37philitic  poisons. 
The  condition  of  the  lungs,  kidneys,  and  other  organs  must 
not  be  overlooked.  [If  the  inquiry  could  be  limited  to  cases 
dependent  on  functional  (?)  origin,  some  assistance  would  be 
obtained  from  considering  the  time  at  which  the  sleep  disturb- 
ance occurs;  for  the  reason  that  sufferers  from  insomnia  from 
these  causes  maybe  roughly  divided  into  two  classes:  (1) 
those  who  are  unable  to  fall  asleep;  and  (2)  those  who  fall 
asleep  easily,  but  soon  awaken. 

(1)  Those  who  are  unable  to  fall  asleep  when  they  go  to 
bed.    This  is  usually  due  to  activity  in  the  brain,  maintained 
(a)  by  the  effects  of  overwork,  worry,  fear,  hysteria,  or  of  tea 
or  coffee,  etc.;  (b)  in  consequence  of  an  increased  blood-supply 
(preventing  its  quiescence)  arising  from  disturbing  agencies 
in  the  economy,  as  cold  feet,  pruriginous  irritations,  acute 
dyspepsia,  or  feverish  states,  implying,  as  these  do,  the  quick- 
ening of  the  circulation  to  the  extent  of  from  eight  to  ten 
beats  for  every  degree  of  increased  temperature. 

(2)  Those  who  fall  asleep  easily,  but  whose  slumbers  soon 


Insomnia  and  its  Therapeutics.  55 

terminate  in  a  vigil.  They  embrace  two  sections,  (a)  Those 
who  possess  impressionable  cerebral  cells,  as  in  neurasthenia, 
hypochondriasis,  night  terrors,  etc.  Such  cells,  being-  pecu- 
liarly sensitive,  perceive  speedily  and  acutely  trifling  disturb- 
ances in  the  system.  (6)  Those  whose  cerebral  cells  are  ren- 
dered irritable  by  an  impure  blood-supply,  such  as  accrues 
from  a  disordered  metabolism,  as  in  hepatic  and  intestinal 
dyspepsia;  or  pertains  to  gout,  rheumatism,  and  syphilis.  It 
must,  however,  be  remembered  that  there  remain  many  ex- 
ceptions to  such  a  classification.] 

The  various  instruments  used  in  diagnosis  must  be  called 
into  requisition,  although  less  assistance  is  derived  from  the 
ophthalmoscope  and  sphygmograph  than  one  would  a  priori 
have  expected. 

It  may  here  be  added  that  dreams  are  not  yet  sufficiently 
understood  to  be  valuable  as  a  means  of  diagnosis.  ThejT  pre- 
lude insanity,  apoplectic  and  epileptic  seizures;  the  menstrual 
periods;  phthisis  pulmonalis,  and  the  continued  fevers.  They 
are  seldom  absent  in  congestive  conditions  of  the  brain  and  its 
membranes;  in  valvular  heart  disease;  aneurism;  chronic  dis- 
eases of  the  lungs,  and  in  dyspepsias.  A  dream  occurring  at 
rare  intervals  is  usually  attributable  to  indiscretion  in  eating 
or  drinking.  It  is  worthy  of  note  that  many  gouty  persons, 
who  dream  a  great  deal,  affirm  that  it  does  not  seem  to  inter- 
fere with  the  restoration  of  their  nervous  energy. 

Prognosis. — The  value  of  sleep  in  prognosis.  Hippocrates, 
in  discussing  prognostics,  wrote  with  regard  to  sleep :  "As  is 
usual  with  us  in  health,  the  patient  should  wake  during  the 
day  and  sleep  during  the  night.  If  this  rule  be  anywise  altered 
it  is  so  far  worse,  but  there  will  be  little  harm,  provided  he 
sleep  in  the  morning  for  the  third  part  of  the  day ;  such  sleep 
as  takes  place  after  this  time  is  more  unfavorable;  but  the 
worst  of  all  is  to  get  no  sleep  night  or  day,  for  it  follows  from 
this  symptom  that  the  insomnolency  is  connected  with  sorrow 
and  pains,  or  that  he  is  about  to  become  delirious/'  He  like- 
wise gave  three  aphorisms  connected  with  sleep:  "In  what- 
ever disease  sleep  is  laborious  it  is  a  deadly  symptom;  but  if 
sleep  does  good  it  is  not  deadly  "  (he  evidently  refers  to  coma). 
"When  sleep  puts  an  end  to  delirium  it  is  a  good  symptom; 
when  it  increases  delirium  it  is  deadly.  Both  sleep  and  in- 
somnolency, when  immoderate,  are  bad." 


56  Insomnia  and  its  Therapeutics. 

The  capacity  for  sleep  is  always  an  important  factor  in 
prognosticating1  the  question  of  recovery  from  a  serious  ill- 
ness, or  the  advisability  of  operative  interference;  it  being-  a 
rule,  to  which  there  are  few  exceptions,  that  the  better  a  pa- 
tient sleeps  the  greater  are  his  chances  of  recovery.  Sir  James 
Paget  wrote  in  1867  concerning  the  various  risks  of  operations: 
"A  better  sign  is  the  capacity  for  sleep.  If  a  patient  can 
always  sleep  long  at  a  spin,  that  is  a  good  patient/' 

Natural  sleep,  returning  and  becoming  sounder  in  intensity 
and  longer  in  duration,  in  the  course  of  a  severe  disease,  is 
always  an  excellent  omen,  and  one  to  be  relied  upon,  even 
when  the  other  symptoms  appear  not  to  justify  it.  It  is  of 
equally  good  import  in  less  pronounced  affections. 

Wakeful  and  restless  nights  supervening  in  the  course  of 
a  prolonged  illness  are  often,  if  not  always,  indicative  of  an 
unfavorable  change,  or  of  a  relapse.  Occasionally  they  derive 
additional  importance  from  the  fact  that  they  precede  all 
other  unpropitious  symptoms,  the  cerebral  cells  apparently 
perceiving  and  evincing  the  effects  of  alterations  in  the  system 
before  any  of  the  other  structures. 

In  regard  to  young  children,  the  following  remarks  of 
Henoch  are  worth  quoting:  "In  judging  of  the  condition  of 
new-born  infants  and  children  at  the  breast,  I  should  further 
recommend  you  to  observe  how  the  hands  are  held  during 
sleep.  Healthy  children  at  this  age  sleep,  as  is  well  known, 
with  their  arms  flexed  to  such  an  extent  that  the  hands  are 
directed  right  upward  and  are  on  a  level  with  the  neck  or 
lower  jaw.  This  attitude — which  is  perhaps  a  reminiscence  of 
intra-uterine  life — is  changed  in  the  case  of  serious  illness,  and 
its  presence  may  consequently  be  regarded  as  a  reassuring 
sign." 

It  is  found  that  people  who  usually  sleep  well  in  health 
often  do  so  also  during  illness;  while  those  whose  sleep  is 
never  very  sound  have  their  rest  more  seriously  interfered 
with  when  they  are  ill^  this  being,  as  already  said,  a  factor 
which  adds  considerably  to  their  peril. 

Treatment. — It  goes  without  saying  that  the  cure  of  sleep- 
lessness is  sleep.  If  the  definition  of  insomnia  given  in  the 
opening  sentence  of  this  chapter  is  accurate,  sleep  can  only  be 
obtained  by  allaying  the  vigilance  of  the  cerebral  cells.  To 
accomplish  this,  we  must  unravel  the  abnormal  condition  in 


Insomnia  and  its   Therapeutics.  57 

the  economy  which  originates  it,  so  that  the  exciting-  cause 
may  be  removed  and  any  predisposing-  cause  alleviated,  as  far 
as  it  is  possible.  In  this  manner  the  health  and  stability  of 
the  cerebral  cells  are  re-established  and  their  healthy  func- 
tion, sleep,  restored.  The  method  in  which  this  may  be  best 
achieved  will  be  treated  fully  in  the  following  pages.  We 
may  here  offer  a  few  preliminary  remarks  on  treatment. 

First,  as  regards  habit  of  sleep,  to  which  we  have  already 
referred  (p.  542),  there  can  be  no  doubt  that  sleeplessness  is 
frequently  the  result  of  the  acquirement  of  a  bad  habit,  either 
as  regards  the  regularity  and  duration  of  sleep,  or  the  prac- 
tice of  taking  with  us,  into  the  hours  which  ought  to  be  de- 
voted to  repose,  the  worries  and  anxieties  of  our  daily  life. 
These  evils  stamp  themselves  upon  the  nervous  system  in  the 
same  way  that  over-indulgence  in  alcoholic  stimulants  does, 
and,  like  the  latter,  are  very  difficult  to  root  out.  This  influ- 
ence of  habit  is  well  exemplified  in  many  aged  persons,  who 
.  in  their  youth  were  accustomed  to  rise  at  an  early  hour  in  the 
morning,  and  who  in  consequence  have  continued  to  do  so 
throughout  their  lives;  and  also  by  the  loss  of  sleep  which 
some  experience  when  sleeping  in  a  strange  bedroom,  although 
the  bed  and  surroundings  are  even  more  comfortable  than 
those  to  which  they  are  habituated. 

The  writer  has  intimate  knowledge  of  a  man  who  now 
sleeps  soundly  for  eight  hours  every  night,  having  succeeded, 
bjr  dint  of  a  determined  effort  of  the  will,  in  overcoming  a 
sleepless  habit  that  for  years  afflicted  him.  Every  one  ought 
to  cultivate  the  habit  of  retiring  punctually  at  a  certain  hour, 
divesting  the  mind,  as  far  as  it  is  possible,  of  care,  so  as  to 
fall  asleep  at  once,  and  of  rising  at  the  instant  of  awaking  in 
the  morning.  Early  rising  is  not  for  its  own  sake  to  be  ad- 
vised, unless  the  hour  of  retiring  to  rest  is  correspondingly 
early. 

The  conditions  of  sleep  as  regards  warmth,  light,  ventila- 
tion, etc.,  are  of  some  importance ;  and  to  them  frequent  refer- 
ence must  be  hereafter  made.  The  bed-clothes  should  be 
warm,  but  light,  and  the  temperature  of  the  apartment  about 
58°  Fahr.  A  heated  atmosphere  is  prejudicial  to  sleep,  it  being 
a  matter  of  common  experience  that  during  a  hot,  airless, 
summers  night  sleep  is  restless  and  disturbed,  especially  in 
children;  this  being  due  to  the  heat  causing  acceleration  of 


58  Insomnia  and  its  TJicrapeutics. 

the  action  of  the  heart,  with  consequent  hyperaemia  of  the 
brain.  A  low  temperature  is  equally  hurtful,  and  acts  by 
causing  contraction  of  the  cutaneous  blood-vessels,  which  is 
followed  by  cerebral  congestion  and  insomnolency.  This  con- 
dition of  things  should  be  carefully  guarded  against  by  the 
aged,  whose  powers  of  resistance  and  reaction  are  feeble.  The 
same  effect  is  often  produced  by  cold  feet.  In  short,  the  most 
favorable  conditions,  as  regards  temperature,  for  securing 
quiet,  refreshing  sleep,  are  those  in  which  the  surface  of  the 
body  is  kept  moderately  warm  and  the  brain  in  a  state  of 
partial  depletion. 

Next  to  a  comfortable  temperature,  thorough  ventilation 
is  of  the  greatest  importance.  When  circumstances  permit, 
it  is  desirable  to  have  the  window  open  a  little  way  at  the  top, 
taking  care,  by  means  of  curtains  and  other  devices,  to  pro- 
tect the  body  from  draughts.  It  is  often  possible  to  do  this 
by  opening  a  window  in  an  adjoining  room.  In  this  way,  con- 
tamination of  the  air  with  the  products  of  respiration  is 
avoided,  for  although  carbonic  acid  may  induce  drowsiness,  it 
does  not  cause  sound  sleep,  its  toxic  effects  being  noticeable  in 
the  headache,  languor,  and  disinclination  to  exertion  present 
after  sleeping  all  night  in  an  ill-ventilated  bedroom. 

It  is  not  desirable  to  sleep  in  a  room  containing  plants  of 
any  kind. 

Last  j'ear  it  was  proposed  ("  Lancet,"  1888)  to  induce  sleep 
by  interfering  temporarily  with  the  perfect  aeration  of  the 
blood,  by  holding  the  breath  after  a  deep  inspiration  until  dis- 
comfort ensued,  and  repeating  the  process  a  few  times. 

If  disturbing  noises  cannot  be  put  a  stop  to,  the  ears  may 
be  plugged  with  cotton  wool,  or  Dr.  Ward  Cousins'  sound- 
deadeners  employed. 

It  is  hardly  necessary  to  suggest  the  avoidance  of  all 
smells. 

Light  should  be  excluded  by  means  of  dark  blinds,  and 
light  in  the  room  dispensed  with,  except  in  the  case  of  children, 
timid  persons,  or  some  sufferers  from  hysteria  and  hypochon- 
driasis,  to  whom  a  well-shaded  light  is  frequently  a  great 
comfort. 

The  bed  ought  to  be  yielding,  without  being  too  soft,  the 
pillows  moderate^7  firm,  and  either  high  or  low  according  to 
the  taste  of  the  sleeper.  The  conditions,  in  short,  should  be 


Insomnia  and  its   Therapeutics.  59 

such  as  to  insure  the  minimum  of  external  stimulations, 
which,  as  \ve  have  already  seen,  tend  to  prevent  and  disturb 
sleep.  The  writer  is  informed  that  the  grievance  of  which 
some  criminals  complain  most  is  the  plank  bed  on  which  they 
are  required  to  recline. 

The  best  position  of  the  body  during  sleep  is  that  instinct- 
ively selected  by  the  sleeper.  The  great  majority  of  people 
sleep  upon  either  side,  the  larger  portion  preferring  the  right 
side,  while  probably  one  out  of  every  five  assumes  the  dorsal 
position,  which  is  generally  considered  to  be  the  least  desir- 
able. The  custom  of  assuming  peculiar  postures  during  sleep 
appears,  in  some  cases,  to  be  hereditary. 

It  has  long  been  a  popular  opinion  that  lying  with  the 
body  in  a  particular  direction,  north  or  south,  improves  sleep 
by  allowing  "the  magnetic  currents  pervading  the  globe  to 
exert  a  certain  influence  on  the  iron  contained  in  the  body." 
Much  stress  has  been  laid  upon  the  advisability  of  placing  the 
bed  so  that  the  head  should  point  to  the  north. 

Many  years  ago  the  writer's  attention  being  directed  to 
this  subject,  he  made  extensive  observations  and  inquiries  re- 
garding it,  but  was  unable  to  satisfy  himself  that  it  exercised 
any  influence  upon  sleep  at  all,  the  apparent  successes  of  the 
method  being,  in  his  opinion,  accidental  rather  than  conse- 
quent, or  resulting  from  the  imagination. 

In  sleeping  in  a  train  the  head  should  be  directed  toward 
the  engine. 

It  is  important  in  the  case  of  those  whose  work  is  chiefly 
mental,  that  a  certain  amount  of  bodily  fatigue  should  be  in- 
duced daily  by  exercise  in  the  open  air;  if  this  is  disregarded 
sleep  is  liable  to  be  interfered  with.  Brain-work  should  be  de- 
sisted from  at  least  an  hour  before  retiring,  and  conversation, 
light  reading,  or  recreation  indulged  in.  Ptolemy,  king  of 
Egypt,  was  wisely  told  that  the  best  way  to  sleep  "  A\  as  to 
have  divine  and  celestial  meditations,  and  to  use  honest  actions 
in  the  daytime." 

He  who  would  sleep  well  must  go  to  bed  "  animo  securo, 
quieto,  et  libero." 

The  food  must  be  proportioned  to  the  work  of  the  body 
and  to  the  strength  of  digestion. 

The  last  meal  is  an  important  one  in  connection  with  sleep. 
If  a  heavy  meal,  it  ought  to  be  partaken  of  from  three  to  four 


60  Insomnia  and  its   Therapeutics, 

hours  beforer  going  to  bed.  If  food  be  taken  at  a  later  hour, 
it  should  consist  of  clear  soup,  which  can  be  readily  absorbed 
loy  the  stomach,  and  farinaceous  food,  that  the  salivary  fer- 
ment can  change.  In  this  way  gastric,  hepatic,  and  intestinal 
digestion — so  apt  to  disturb  sleep — is  rendered  unnecessary. 
The  stomach  should  not  be  struggling  with  a  burden,  nor  feel- 
ing the  effects  of  want. 

Insomnia  is  frequently  benefited  by  climatic  change.  This 
is  brought  about  by  the  altered  physiological  conditions  influ- 
encing favorably  the  disturbance  upon  which  it  depen'ds.  In 
considering  the  therapeutics  of  a  climate  in  this  connection,  it 
is  wise  to  be  guided,  to  some  extent,  by  the  previous  personal 
experience  of  the  patient,  and  to  recollect  that  if  sleep  is  faulty 
or  imperfect  it  will  more  than  counterbalance  any  benefit 
which  might  be  derived  from  atmospheric  change.  It  is  a 
fact  worthy  of  note  that  localities  in  which  people  sleep  soundly 
when  they  are  well,  generally  suit  them,  in  this  regard,  when 
they  are  ill. 

The  duration  of  sleep  must  not  be  trusted  as  the  sole  guide 
in  this  matter,  for  the  sense  of  recuperation,  as  has  been  al- 
ready pointed  out,  is  a  more  reliable  one.  There  is  a  quality 
in  sleep  as  well  as  a  quantity;  therefore  it  cannot  be  judged 
altogether  by  its  duration.  Such  measures,  by  alleviating 
perturbing  elements  in  the  economy,  toning  the  vascular  sys- 
tem, and  strengthening  and  calming  the  nervous  centres,  fre- 
quently suffice  alone  to  palliate  wakefulness  and  to  restoj 
natural  sleep. 

If  in  spite  of  these  curative  means  insomnia  persists,  atten- 
tion must  be  directed  to  the  attainment  of  three  points.  The 
quiescence  of  excitability  and  activity  in  the  psychical  centres. 
This  can  be  accomplished  by  means  of  remedies  which  act  di- 
rectly upon  the  nervous  textures  and  calm  the  activity  of  the 
cells,  thus  allowing  the  blood-supply  to  slack  off.  The  diminu- 
tion and  tranquillization  of  the  cerebral  blood-supply.  (It 
has  already  been  stated  that  cellular  activity  necessitates  an 
augmented  vascular  supply,  just  as  increased  vascularization 
implies  activity.)  This  can  be  achieved  by  medicines,  chiefly 
tonics,  whose  properties  act  specially  upon  the  great  centres 
in  the  medulla,  and  through  their  agency  quiet  the  heart  and 
give  tone  to  the  blood-vessels,  so  as  to  diminish  the  force  and 
volume  of  "the  blood  current.  The  modification  of  the  quality 


Insomnia  and  its   TJierapeutics.  61 

of  the  blood.  This  can  be  brought  about  by  medicines  which 
increase  the  number  of  the  corpuscles,  or  act  favorably  upon 
poisonous  constituents.  Sleep  so  induced  frequently  terminates 
in  natural  sleep. 

Hypnotics  act  in  various  ways,  some  affecting  one  portion 
of  the  nervous  system  more  than  the  others. 

Dr.  Lauder  Brunton,  in  the  Croonian  Lectures  already  re- 
ferred to,  states  that  "  hypnotics  may  probably  lessen  the 
functional  activity  of  the  cerebral  cells,  by  causing  their  pro- 
toplasm to  contract,  and  thus  interposing  a  barrier  of  para- 
plasm  between  it  and  the  oxygen  brought  by  the  blood,  and 
by  lessening  the  affinity  of  the  cells  for  oxygen  by  diminish- 
ing their  alkalinity,  or  by  entering  into  actual  combination 
with  them  for  a  time,  and  thus  altering  their  chemical  rela- 
tionships." 

Alcohol  taken  in  the  form  of  whiskey  or  brandy  of  goof 
I  ^ualityaiid~in  judicious  quantity  is  probably  one  of  the  jnost, 
I  reliable  and  least  hurtful  hypnotics  we  possses.  Its  efll 
""""has  stood  the  test  oftlme^  Many  memTJErs  ot  tne"alcohol  groui 
act  ashypnotics!  They  simply  induce  sleep  as  one  of  the  first 
effects  of  their  action.  In  larger  doses,  however,  they  may 
cause  complete  unconsciousness  and  anaesthesia  and  abolish 
the  reflexes.  For  the  production  of  prolonged  sleep  it  is  nec- 
essary to  administer  a  remedy  whose  action  is  at  once  mild 
and  of  some  duration,  that  the  untoward  results  referred  to 
may  be  avoided.  For  such  a  substance  we  look  among  the 
compounds  which  contain  a  heavy  molecule,  whether  these  are 
solid  or  liquid  in  form.  It  is  usually  best  to  prescribe  them  by 
the  mouth,  that  they  may  be  gradually  absorbed  into  the 
blood  and  continue  to  act  for  a  protracted  time.  Recently 
several  new  remedies  have  been  introduced,  which  seem  likely 
to  take  a  high  and  permanent  place  in  the  materia  medica. 
Among  these  must  be  specially  mentioned  sulphonal,  chloral- 
amide,  and  paraldehyde;  and  in  a  less  prominent  way  urethane, 
hypnone,  and  the  tertiary  nitrite  amylene  hydrate.  So  far,  no 
one  of  these  has  been  found  free  from  all  objection,  although 
they  are  very  superior  in  many  respects  to  the  bulk  of  the 
older  remedies. 

Such  a  rapid  advance  is  being  made  at  present  in  aug- 
menting this  class  of  remedies,  owing  to  the  many  new  com- 
pounds which  synthetical  chemistry  has  brought  into  existence, 


62  Insomnia  and  its   Therapeutics. 

possessing  strong1  hypnotic  properties,  that  \ve  may  confi- 
dently look  forward  to  the  fabrication  of  one  which  will  safely 
and  benignly  induce  sleep. 

The  benefits  to  be  derived  from  hypnotics  are  most  con- 
spicuously seen  in  acute  diseases,  such  as  inflammations, 
fevers,  etc.,  where  it  is  necessary  to  prolong  life  by  conserv- 
ing strength,  until  the  natural  crisis  of  the  affection  arrives; 
the  greatest  of  all  conservative  agents  being  sleep.  Every 
eight  hours'  sleep  out  of  twenty-four  represents  an  enormous 
saving  of  energy;  the  heart  beating  five  thousand  times  less, 
the  respirations  being  one  thousand  five  hundred  fewer,  while 
the  temperature  remains  at  a  lower  point.  If  to  this  it  be 
added  that  the  products  of  waste  are  more  perfectly  removed 
from  the  sj'stem,  it  becomes  apparent  how  very  desirable  sleep 
is  in  acute  diseases,  and  particularly  in  those  of  the  nervous 
system  and  of  the  lungs  and  heart. 

In  chronic  affections,  hypnotics  fill  a  more  limited  sphere 
of  usefulness;  still,  the  benefits  gained  from  a  few  nights'  sleep 
secure  at  least  three  distinct  advantages:  time  is  acquired  for 
the  remedying  of  the  ailment;  the  cerebral  cells  are  rested 
and,  with  the  whole  body,  are  strengthened,  thus  permitting 
their  excitability  to  subside;  it  often  allows  a  sleep  habit  to 
be  established.  To  this  extent  their  use  is  helpful,  and  it  must 
not  be  withheld. 

It  is,  however,  in  such  cases  that  one  is  apt  to  forget  that 
hypnotics  are  not  per  se  curative;  to  continue  their  adminis- 
tration indefinitely  is  to  misuse  them.  Coincident  with  the 
widely-spread  abuse  of  these  drugs  there  has  sprung  up  a 
fashion  to  inveigh  against  their  employment  at  all,  but  it 
must  be  urged  that  drug-induced  sleep  is  better  than  no  sleep. 
There  is  a  vast  amount  of  evidence  to  prove  that  the  use  of 
hypnotics  in  strictly  medicinal  doses  is  not  so  detrimental  to 
health  as  is  commonly  supposed.  There  are  many  men  of 
advanced  years,  occupying  high  positions  in  this  country,  who 
for  years,  ay,  for  half  a  century  in  some  instances,  have  never 
gone  to  bed  at  night  without  a  soporific,  and  so  far  from  suffer- 
ing in  health,  have  benefited  by  the  practice.  Although  it  is 
far  from  our  purpose  to  advocate  or  countenance  the  use,  and 
particularly  the  misuse,  of  drugs  of  any  description,  yet  we 
must  conclude  that  the  experience  of  the  efficacy  of  hypnotics, 
accumulated  during  centuries,  is  based  upon  a  sound  founda- 


Insomnia  and  its   Therapeutics.  63 

tion  and  must  endure.  Remedies  which,  skilfully  selected  and 
rightly  administered,  are  able  to  conserve  life,  preserve  reason, 
and,  in  less  urgent  cases,  to  influence  an  affection  favorably, 
cannot  be  lightly  discarded. 

At  the  same  time  it  must  be  remembered  that  many  ob- 
stinate cases  of  insomnia  can  be  managed  and  cured  without 
the  employment  of  hypnotics;  and  when  that  is  accomplished 
it  illustrates  the  truth  of  the  old  saying  that  "  the  best  medi- 
cine is  none/' 

If  a  patient  awake  during  the  night  and  is  unable  to  fall 
asleep  again,  he  should  on  no  account  lie  tossing  about  worry- 
ing at  his  fate.  Such  a  course  invariably  prevents  the  return 
of  sleep.  It  is  better  to  rise  and  walk  two  or  three  times 
round  the  room,  brush  the  hair,  take  a  drink  of  water,  and 
then  go  back  to  bed.  If  that  does  not  prove  efficacious,  he 
should  light  a  candle,  and  take  to  a  novel  or  other  light  read- 
ing, that  he  may  occupy  his  mind.  It  is  at  once  a  comfort 
and  an  aid  to  sleep. 


CHAPTEE  III. 

INSOMNIA  DEPENDING  UPON  AFFECTIONS  OF  THE 
NERVOUS  SYSTEM. 

OVERWORK. 

THIS  term  in  the  following  lines  is  applied  to  conditions 
arising-  out  of  excessive  mental  effort ;  it  refers  to  an  undue 
strain  on  the  intellectual  apparatus. 

In  different  persons  the  capacity  for  mental  work  varies 
very  remarkably,  one  man  being-  able  to  overtake  easily  an 
amount  of  labor,  without  apparent  detriment  to  health,  which 
another  finds  quite  beyond  his  scope,  both  in  quantity  and 
quality.  Every  one  has  his  own  individual  range,  the  limits 
of  which  he  cannot  exceed  with  impunity. 

The  term  "  overwork,"  then,  is  necessarily  used  in  a  relative 
sense.  Its  effects  are  chiefly  seen  in  the  literary,  scientific, 
professional,  and  commercial  classes,  and  in  children;  being 
largely  caused  by  the  fierce  competitive  struggle  of  the  pres- 
ent day.  It  is  one  of  the  great  sources  of  insomnia. 

Reference  has  already  been  made  to  the  fact  that  an  in- 
active brain  during  waking  moments  (as  in  the  condition 
known  as  "  thought  drifting  ")  is  comparatively  bloodless,  and 
of  smaller  size  than  when  in  active  function.  During  mental 
operations  some  of  the  psychical  areas  are  called  into  activity; 
the  blood-vessels  supplying  these  dilate,  more  blood  is  conveyed 
to  the  parts,  and  the  brain  increases  in  size.  If  the  particular 
intellectual  occupation  is  changed  for  another,  a  fresh  group 
of  centres  is  brought  into  requisition,  which  in  their  turn 
grow  hyperaemic,  while  those  first  in  use,  becoming  quiescent, 
resume  their  normal  or  comparatively  anaemic  state.  (It  has 
been  clearly  demonstrated  by  Mosso  that  hyperaemia  of  the 
brain  is  coincident  with  mental  work.  It  seems  legitimate  to 
argue  from  analogy  that  this  increased  blood-supply  is  limited 
to  the  active  portions  of  the  brain,  and  not  uniformly  dis- 
tributed to  every  portion.  Therefore,  while  the  writer  is  well 


Insomnia  and  its   Therapeutics.  65 

aware  that  no  such  localized  anatomical  apportionment  has 
been  shown  to  take  place,  he  thinks  it  a  very  reasonable 
proposition,  and  it  is  certainly  a  very  attractive  and  conve- 
nient working-  theory.  The  theory,  moreover,  appears  to  be 
justified  on  the  further  ground  that  the  cerebral  blood-vessels 
are  terminal,  and  do  not  anastomose  freety  one  with  another. 
They  are  thus  capable  of  vascularizing  certain  limited  areas 
without  increasing  the  blood  supply  of  the  brain  generally.) 
These  are  healthy  and  physiological  processes,  just  as  needful 
for  the  proper  nutrition,  growth,  and  development  of  the  brain 
and  its  powers,  as  are  muscular  contractions  for  the  nutrition 
and  development  of  a  muscle;  and  as  disuse  in  the  latter  case 
is  surely  followed  by  atrophy,  so,  in  the  former,  does  it  lead  to 
mental  lethargy  and  decay  of  function. 

When  mental  work  of  an  arduous  and  engrossing  kind  is 
pursued,  particular  psychical  sites  are  extremely  active,  and 
toiling  at  their  highest  possible  pressure.  At  first,  when  the 
reserve  fund  of  nerve  force  is  considerable,  the  deleterious  con- 
sequences of  straining  are  not  apparent,  for  during  the  hours 
of  rest  these  sites  recover  their  normal  condition,  and  recu- 
perative changes  are  effected,  so  that  work  can  be  resumed 
as  usual  on  awaking.  This  is  accomplished  by  means  of  the 
vaso-motor  nerve,  whose  function  it  is  to  regulate  the  blood- 
supply  to  the  amount  of  work  being  carried  on. 

When,  however,  this  high  pressure  is  obstinately  main- 
tained, there  conies  a  time,  sooner  or  later,  depending  mainly 
upon  the  stability  of  the  nervous  tissues,  when  these  physio- 
logical arrangements  begin  to  fail,  and  the  active  centres  be- 
come weary,  jaded,  and  irritable.  The  vaso-motor  nerves, 
being  inhibited  during  lengthened  periods,  grow  exhausted 
and  paretic,  and  become  unable,  on  temporary  cessation  of 
mental  work,  to  cause  contraction  of  the  blood-vessels  as  they 
ought  to  do,  so  that  a  condition  of  local  chronic  hypereemia  is 
excited  in  the  particular  centres  in  use,  and  these  sites  becom- 
ing exhausted,  the  case  assumes  a  pathological  aspect.  It 
constitutes  an  example  of  derangement  accruing  from  work 
imposed  upon  the  cerebral  textures  being  badly  arranged  and 
in  excess  of  their  powers.  When  this  stage  has  been  reached, 
work  may  still  be  carried  on  by  a  powerful  effort  of  the  will, 
but  sleeplessness  becomes  pronounced,  the  general  health 
gives  way,  and  the  breakdown  is  complete. 


66  Insomnia  and  its  Therapeutics. 

The  symptoms  which  such  persons  present  are  tolerably 
uniform.  Sleeplessness  is  one  of  the  most  urgent,  being  usu- 
ally associated  with  throbbing  blood-vessels  and  restless  cere- 
bration. When  sleep  does  occur  it  is  disturbed,  unrefreshing, 
and  accompanied  by  dreams,  and  as  these  are  dependent  upon 
activity  in  the  centres  called  into  function  by  the  work  en- 
thralling the. -mind,  the  dreams  are  usually  connected  with 
one's  daily  toil. 

Exhaustion  and  misery  are  felt  in  the  morning;  depression, 
despondency,  and  irritability  during  the  day.  All  mental  and 
plrysical  work  is  accomplished  with  an  effort,  concentration 
of  thought  is  difficult,  and  headache  is  seldom  absent.  The 
overworked  man  looks  worn  and  anaemic,  and  has  a  soft,  com- 
pressible pulse;  although  in  some  cases  he  is  plethoric,  with 
bright  eyes  and  a  hard,  tense  pulse.  In  both  types,  the  brain 
and  nervous  system,  being  neither  recuperated  nor  relieved 
of  their  waste  products,  innervate  the  various  organs  of  the 
body  defectively;  and  so  dyspepsia,  constipation,  and  palpita- 
tion of  the  heart  are  generally  complained  of;  and  the  urine 
may  contain  oxalate  of  lime,  or  an  excess  of  phosphates. 

It  will  be  gathered,  from  consideration  of  the  foregoing 
sentences,  that  it  is  an  exclusive  or  almost  exclusive  use,  or 
rather  misuse,  of  a  particular  and  limited  portion  of  the  brain 
which  leads  to  the  portrayed  disaster.  An  analogous  instance 
of  the  same  thing  occurring  in  another  system  is  to  be  found 
in  writer's  cramp,  where  the  constant  use  of  a  particular  set 
of  muscles  is  followed  by  serious  disorder.  Another  proof,  if 
proof  were  needed,  of  the  evil  effects  of  prolonged  and  unvaried 
mental  toil,  is  to  be  found  in  the  fact  that  \vhen  insanity  super- 
venes upon  mental  overwork,  it  occurs  chiefly,  if  not  entirely, 
among  those  whose  work  is  of  a  protracted,  monotonous,  and 
undiversified  description. 

The  import  of  sleeplessness  is  apt  occasionally  to  be  mis- 
apprehended. Some  years  ago  the  writer  was  intimately  ac- 
quainted with  a  man  who  was  engaged  in  literary  work  of  a 
hopeful  kind,  and  who,  though  obviously  suffering  from 
mental  strain,  was  wont  to  congratulate  himself  upon  his 
special  power  of  dispensing  with  sleep,  making  calculations  as 
to  how  many  years  of  his  life  he  had  lost  in  sleep  during  the 
course  of  his  career.  For  a  long  time  he  worked  well  on  an 
allowance  of  six  hours'  sleep  a  night,  for  a  shorter  time  upon 


Insomnia  and  its   TJierapeutics.  67 

four,  then  upon  two,  and  latterly  he  slept  not  at  all.  He 
turned  a  deaf  ear  to  all  warnings  of  the  dangers  which  he  was 
only  too  surely  incurring-,  until  the  crash  came  in  an  extremely 
severe  attack  of  meningeal  inflammation,  from  which  he 
eventually  recovered,  but  only  to  be  the  wreck  of  his  former 
self. 

The  evils  of  mental  overwork  are  frequently  manifested  in 
children,  owing  to  the  pernicious  system  of  cram  which  pre- 
vails so  extensively  at  the  present  day.  Their  brains  require 
an  unusually  large  amount  of  sleep  for  the  purpose  of  supply- 
ing the  necessary  pabulum  for  growth,  as  well  as  for  the  re- 
moval of  the  products  caused  by  tissue-metamorphosis.  This 
fact  presents  itself  in  a  striking  light  when  it  is  remembered 
that  the  male  brain  reaches  five-sixths  and  the  female  ten- 
elevenths  of  its  full  size  at  the  age  of  seven  years.  When 
children  are  encouraged  to  make  great  strains  upon  the  high- 
est cerebral  centres,  it  frequently  leads  to  brain  irritation,  or 
congestion,  which  shows  itself  in  irritability  and  peevishness, 
headache,  sleeplessness,  or  sleep  accompanied  by  disturbing 
dreams,  loss  of  appetite,  and  failure  of  nutrition  and  strength. 
If  these  symptoms  are  neglected  or  misconstrued,  they  may 
culminate  in  organic  lesions,  such  as  meningitis.  Unfortu- 
nately, brains  that  are  not  allowed  to  grow  naturally,  but 
are  forced,  are  apt  to  become  permanently  weak  and  un- 
stable, and  to  be  the  cause  of  much  trouble  and  misery  in 
after-life. 

Chorea,  of  which  sleeplessness  is  so  common  a  symptom, 
was  found  by  the  Collective  Investigation  Committee  of  the 
British  Medical  Association  to  be  caused  in  seventy-one  cases 
out  of  four  hundred  and  thirty-nine  by  overwork,  fifteen  being 
males  and  fifty-six  females.  Sixty-three  of  these  cases  oc- 
curred in  children  between  the  ages  of  six  and  fifteen  years, 
and  eight  between  fifteen  and  twenty  years. 

Formerly  the  symptoms  of  overwork  in  children  were  com- 
monly ascribed  to  worms  or  low  fever,  the  victims  being  kept 
at  home  from  school  and  dosed  with  drastic  purgatives. 
These  are  excellent  remedies  for  cerebral  congestion,  and  can 
hardly  be  improved  upon  even  now,  though,  with  our  extended 
knowledge  and  experience,  they  are  seldom  required. 

Sleep  is  the  best  criterion  as  to  the  amount  of  work  a  child 
can  do  without  injury  to  health.  So  long  as  sleep  is  sound 


68  Insomnia  and  its   Tlurapcutics. 

and  dreamless  the  question  of  overwork  need  not  be  con-, 
sidered. 

It  has  often  been  urged  that  work  never  kills,  and  probably 
healthy  and  well-arranged  work  never  does.  That  badly- 
balanced,  unvarying,  and  excessive  work  initiates  pathological 
changes  which,  in  children,  lead  to  fatal  terminations,  and  in 
adults  to  disastrous  consequences,  must  be  within  the  experi- 
ence of  every  physician.  There  certainly  can  be  no  prolonged 
interference  with  sleep  without  the  health  becoming  seriously 
compromised. 

Treatment. — This  will  be  most  advantageous^  considered 
under  the  following  heads :  removal  of  the  cause,  diminution 
of  the  hyperaemia  of  the  nervous  centres,  restoration  of  tone 
to  the  vaso-motor  nerves,  calming  and  strengthening  the 
nervous  centres. 

(1)  Removal  of  the  Cause. — In  most  cases  it  is  best  to 
advise  temporary  cessation  from  all  work  until  health  im- 
proves and  sleep  returns.     The  resumption  of  work  should  be 
gradual,  and   the  method  subjected   to  careful  re-arrange- 
ment upon  strictly  physiological  lines.     The  amount  of  work 
performed  need  not  necessarily  be  more  limited  than  before, 
but  it  should  be  of  a  more  varied  character,  its  range  being 
curtailed  in  some  directions  while  it  is  extended  in  others. 

(2)  Diminution  of  the  Hypercemia  of  the  Nervous  Cen- 
tres.— This  may  be  accomplished  in  several  ways.     Among 
the  most  important  is  change  in  the  character  of  the  work. 
The  benefit  to  be  derived  from  this  diversity  is  well  illustrated 
in  the  lives  of  some  of  our  greatest  men.     Leading  statesmen, 
busy  judges,  those  at  the  head  of  gigantic  business  concerns, 
all  find  it  necessary  to  have  hobbies,  and  find  in  them  sources 
of  relaxation  and  distraction  from  cares  which  would  otherwise 
overwhelm  them,  and  without  which  sleeplessness  and  its  at- 
tendant evils  would  speedily  supervene.     It  is  of  the  highest 
importance  that  patients  be  advised  to  avail  themselves  of 
this  physiological  cure  by  devoting  their  attention  to  light 
reading,  cards,  billards,  or  some  other  amusement  for  an  hour 
before  going  to  bed. 

The  writer  has  long  been  of  opinion  that  the  benefit  derived 
from  billiards,  wood-carving,  playing  musical  instruments, 
such  as  the  piano  or  violin,  etc.,  is  largely  due  to  the  number 
of  cerebral  centres  called  into  requisition.  The  complexity 


Insomnia  and  its  Tlierapeutics.  69 

and  precision  of  the  fine  movements  imply  high  activity  in 
some  motor  centres;  the  sensory  centres  are  stimulated  by 
way  of  the  eye  and  ear;  while  at  the  same  time  the  centres 
of  intellectual  operations  are  brought  into  activity  in  order  to 
correlate  the  whole — a  combination  of  circumstances  the  re- 
sult of  which  will  most  probably  be  depletion  of  the  hyperse- 
mic  centres. 

Many  devices  based  upon  the  same  physiological  grounds 
have  been  suggested  as  means  of  procuring  sleep.  The  thoughts 
are  to  be  concentrated,  by  an  effort  of  will,  on  one  subject, 
preferably  a  monotonous  one,  such  as  in  imagination  singing 
some  melody,  or  counting  sheep  marching  in  single  fill  through 
a  gate,  counting  numbers,  or  one's  own  respirations.  A  medi- 
cal friend  of  great  determination  of  purpose  says  that  he  is 
never  conscious  of  counting  more  than  seventeen  sheep  walk- 
ing through  a  gate  before  he  falls  asleep.  Smiles,  in  his  work 
on  "Life  and  Labor,"  relates  that  "a  missionary  troubled 
with  sleeplessness  repeated  the  Lord's  Prayer  till  Satan  sent 
him  to  sleep  to  get  rid  of  it,  and  he  says  he  never  found  the 
receipt  to  fail." 

The  difficulty  is  in  directing  the  thoughts  exclusively  to 
the  new  subject,  as  it  requires  the  greatest  effort  to  inhibit 
the  activity  of  the  hyperaemic  centres,  and  to  prevent  the  ideas 
from  returning  to  their  accustomed  channels;  indeed,  the 
artifice  often  fails  for  this  reason. 

Other  expedients,  the  physiological  effects  of  which  are,  to 
a  large  extent,  of  a  similar  character  to  the  foregoing,  are 
found  in  change  of  scene — from  the  country  to  the  city,  or  vice 
versa— or  in  travel;  while  a  well-planned  walking  tour,  or  a 
month's  fishing,  hunting,  or  shooting,  for  the  more  robust,  are 
excellent  hypnotics. 

Wordsworth,  who  was  manifestly  acquainted  with  the  use- 
fulness of  such  aids  to  sleep,  as  well  as  with  their  occasional 
inadequacy,  recounts  them  in  the  following  lines : 

"  A  flock  of  sheep  that  leisurely  pass  by 
One  after  one  ;  the  sound  of  rain,  and  bees 
Murmuring  ;  the  fall  of  rivers,  winds,  and  seas, 
Smooth  fields,  white  sheets  of  water,  and  pure  sky ; 
I've  thought  of  all  by  turns,  and  still  1  lie 
Sleepless  ;  and  soon  the  small  birds'  melodies 
Must  hear,  first  utter'd  from  my  orchard  trees, 
And  the  first  cuckoo's  melancholy  cry. 


7O  Insomnia  and  its   Therapeutics. 

Even  thus  last  night  and  two  nights  more  I  lay, 
And  could  not  win  thee,  Sleep!  by  any  stealth; 
So  do  not  let  me  wear  to-night  away. 
Without  thee  what  is  all  the  morning's  wealth? 
Come,  blessed  barrier  between  day  and  day, 
Dear  mother  of  fresh  thoughts  and  joyous  health  ! " 

In  these  cases  the  writer  relies  much  upon  the  use  of  the 
Turkish  bath  under  medical  advice,  as  a  curative  agent;  for 
as  a  derivative,  depurative,  and  tonic  it  has  no  equal,  relieving 
the  cerebral  congestion  and  toning  the  nervous  and  circula- 
tory systems,  thereby  aiding  digestion  and  assimilation  (Chap. 
XVII.).  The  lamp  bath  and  the  sitz  bath,  although  inferior  to. 
the  Turkish,  are  sometimes  serviceable.  Several  other  applica- 
tions of  hydrotherapy,  which  are  all  more  or  less  useful  in  the 
cases  under  consideration,  may  be  mentioned.  One  of  these 
consists  in  douching  the  head  with  cold  water  at  bedtime; 
and  this  may  be  combined  with  the  use  of  moist  applications 
to  the  feet  and  legs.  Good  effects  are  said  to  be  got  from  a 
pair  of  wet  cotton  socks  worn  all  night  covered  with  a  pair 
of  thick  woollen  ones.  The  writer  has  frequently  seen  good 
results  follow  the  use  of  wet  towels  rolled  round  the  legs  and 
worn  during  the  night.  Such  appliances,  however,  occasion- 
ally prevent  sleep  by  acting  as  disturbants.  Of  much  more 
service  than  these  partial  remedies  is  the  employment  of  the 
wet  pack  immediately  before  bedtime.  Reference  to  this 
measure  is  made  at  some  length  elsewhere. 

Bodily  exercise  is  a  valuable  curative  in  these  cases  of  in- 
somnia, attracting  a  large  supply  of  blood  to  the  muscles  and 
skin,  and  acting  as  a  powerful  derivative  to  the  brain,  while 
it  increases  cardiac  action  and  vascular  tension.  On  discon- 
tinuing the  exertion  these  states  are  reversed;  the  heart  beats 
more  quietly,  the  blood-pressure  is  lowered,  and  sleep  becomes 
possible.  Exercise  should  be  taken  in  the  open  air,  and  be 
proportioned  to  the  strength  of  the  patient,  all  fatigue  being 
avoided.  The  form  most  desirable  for  a  particular  case  re- 
quires some  consideration.  Walking,  riding,  gymnastics,  etc., 
have  each  its  special  advantage;  and  in  many  instances,  walk- 
ing or  riding  to  and  from  business  is  all  that  is  necessary  to 
promote  sleep. 

In  those  instances  in  which  the  general  vascular  tension  is 
much  increased,  alkalies,  combined  with  tincture  of  aconite, 


Insomnia  and  its   Therapeutics.  71 

may  be  advantageously  prescribed,  and  their  action  is  aug- 
mented by  saline  purgatives.  In  some  few  cases  it  may  be 
necessary  to  resort  to  depletion,  but  dry  cupping  to  the  neck 
and  upper  part  of  the  shoulders  will  generally  suffice. 

Restoration  of  Tone  to  the  Vaso-motor  Nerves. — Some 
of  the  foregoing  measures  will  materially  assist  in  accomplish- 
ing this  object,  but  it  is  occasionally  desirable  to  administer 
some  tonic  medicine,  more  particularly  in  those  cases  in  which 
the  vascular  tone  is  relaxed.  For  many  years  the  writer  has 
prescribed,  with  most  excellent  results,  a  combination  of  nux 
vomica  and  hyd  rob romic  acid. 

5  Acid,  hydrobrom., 3  vi. 

Tinct.  nucis  vom.,   .        .        .  3  ij.  vel  3  iij. 

Tinct.  cichon.  rub.,  .        .        .        .        .     3  vi. 

Aquam, ad  3  vi. 

Sig.  A  tablespoonful  in  a  wineglassful  of  water  an  hour 
before  luncheon  and  dinner. 

When  the  urine  contains  an  excess  of  phosphates  or  oxalate 
of  lime  the  following  may  be  substituted : 

IJ  Acid,  nitro-hydrochlor.  dil.,  .        .        .        .    3  iij. 

Liquoris  strychnin., 3  i. 

Tinct.  gent,  co., 3  vi. 

Aquam, ad  §  vi. 

Sig.  A  tablespoonful  immediately  after  meals,  in  water, 
thrice  daily. 

Calming  and  Strengthening  the  Nervous  Centres. — To 
accomplish  this  it  is  necessary  to  direct  attention  to  the  gen- 
eral health.  The  patient  should  cultivate  the  habit  of  going 
to  bed  at  a  regular  hour,  and  of  rising  with  punctuality.  The 
bedroom  should  be  well  ventilated,  and  the  head  raised  upon 
a  high  pillow.  The  hours  for  eating  and  drinking  must  be 
laid  down  with  precision,. the  diet  being  adapted  to  the  tem- 
perament and  digestive  powers,  the  last  meal  being  taken 
some  three  hours  before  going  to  bed.  If  dinner  is  an  early 
meal,  a  cupful  of  some  farinaceous  food,  such  as  milk  arrow- 
root, is  necessary  before  retiring.  Tea,  coffee,  and  tobacco  are 
to  be  used  in  great  moderation,  if  not  discontinued  entirely, 
and  the  excretory  organs  kept  active. 


72  Insomnia  and  its   Therapeutics. 

No  hard-and-fast  rule  can  be  laid  down  as  to  the  employ- 
ment of  alcoholic  stimulants,  each  case  requiring  separate  and 
careful  consideration.  The  plethoric,  whose  A^ascular  tension 
is  already  high,  do  best  without  alcohol  in  any  form;  while 
the  anasmic  are  often  benefited  by  a  moderate  quantity  taken 
with  food  to  promote  digestion,  and  a  "  night-cap  "  of  whiskey 
or  brand}',  with  warm  water  and  sugar.  For  centuries  the 
hypnotic  effect  of  alcohol  in  combination  with  sugar  and  nut- 
meg has  been  recognized,  strong  ale  and  nutmeg  being  a  fa- 
vorite form  for  its  administration.  In  this  connection  it  is 
interesting  to  note  that  Horace,  in  his  "  Satires/'  gives  an  ex- 
cellent prescription  of  Trebatius'  for  this  form  of  insomnia;  it 
is  as  followrs :  "Anointed  let  them  swim  the  Tiber  thrice  who 
require  a  deep  sleep;  let  them  also  have  their  bodies  saturated 
with  wine  at  night" — a  combination  of  stimulant  with  exer- 
cise. On  account  of  its  stimulant  and  derivative  action,  tur- 
pentine in  TTL  xxx.  doses  at  bedtime  is  a  powerful  aid  to  sleep. 
It  suits  best  in  plethoric  cases.  Knowing  how  efficacious  the 
late  Dr.  Warburton  Begbie  found  it  in  the  "  headache  of  a 
fatigued  brain,"  the  writer  was  induced  to  prescribe  it  in  this 
class  of  cases,  and  his  anticipations  were  abundantly  realized. 
It  yields  equally  good  results  in  worry.  It  is  easily  taken  in 
capsules,  which  usually  contain  TH  xv.  each 

If  the  remedies  detailed  fail  to  accomplish  the  end  in  view, 
we  must  resort  to  the  use  of  hypnotics,  which,  by  their  sooth- 
ing effect  on  the  irritable  nervous  textures,  are  calculated  to 
induce  sleep,  and,  in  so  doing,  to  restore  tone  to  the  exhausted 
and  enervated  tissues.  There  are  many  agents  from  which 
to  choose.  The  bromides  are  especially  applicable  in  cases  of 
insomnia  arising  from  overwork,  the  only  centra-indication  to 
their  use  being  anemia,  on  account  of  the  tendency  which 
these  drugs  have  to  lead  to  an  impoverished  state  of  the  blood, 
and  this  itself  is  a  cause  of  sleeplessness. 

The  bromide  of  lithium  of  the  United  States  Pharmacopoeia 
is  the  best  hypnotic  of  the  bromide  salts,  as  it  contains  a  half 
more  bromine  than  the  potassium  bromide.  Its  dose  is  from 
ten  to  twenty  grains.  The  bromides  of  sodium  and  potassium, 
which  are  in  most  frequent  use  in  this  country,  are  given  in 
doses  of  3  ss.  to  3  i.  They  are  best  prescribed  in  syrup  and 
water,  a  full  dose  being  taken  two  hours  before  bedtime,  and 
another  at  bedtime.  If  these  doses  do  not  succeed  in  procur- 


Insomnia  and  its   Therapeutics.  73 

ing  sleep  they  may  be  associated  with  ergot  of  rye  and  digi- 
talis, both  of  which  are  stimulants  of  the  vaso-motor  centres. 

Ijl   Bromidi  lithii,       ......    gr.  xl. 

Extracti  ergotse  liq.,    .        ,        .        .        .    3i. 
Tinct.  digitalis,    .        .        \        .        .        .in,  xx. 
Aquae  chloroform!, 3  xv. 

M.  Sig.  Take  one-half  two  hours  before  going  to  bed,  and 
the  other  half  at  bedtime. 

If  the  bromides  fail  to  induce  sleep  after  eight  days'  trial, 
their  use  should  be  discontinued. 

In  anaemic  cases  where  it  is  advisable  not  to  give  the  bro- 
mides, sulphonal,  paraldehyde,  or  urethane  may  be  tried,  as 
they  are  each  suitable  drugs. 

In  children,  treatment  should  be  conducted  on  like  princi- 
ples, badly  arranged  work  being  interdicted  and  the  child  re- 
moved from  school  and  placed  for  two  or  three  days  in  bed  in 
a  quiet,  cool,  and  darkened  room,  with  cold  applications  to 
the  head,  a  tepid  bath  being  given  night  and  morning.  The 
food  should  be  light  and  bland.  A  purgative  may  be  required, 
as  well  as  potassium  bromide  in  doses  of  one  grain  for  every 
year  of  age,  thrice  daily,  in  some  sweetened  water. 

If  the  symptoms  of  irritation  do  not  .speedily  subside,  six 
or  eight  leeches  must  be  applied  to  the  temples,  all  subsequent 
bleeding  being  checked. 

After  all  headache  and  restlessness  have  disappeared,  a 
change  of  air  and  scene  will  complete  the  cure.  It  is  better 
to  avoid  the  seaside. 

When  the  child  returns  to  school  it  must  be  stipulated 
that  its  lessons  be  more  varied,  and  that  it  should  play  for  at 
least  half  an  hour  after  each  meal. 

The  following  table  is  one  modified  by  the  writer  from  that 
of  Friedlander,  and  contains  his  views  as  to  the  best  division 
to  be  made  of  the  twenty-four  hours  in  the  matter  of  rest, 
work,  and  sleep. 


AGE. 
1  

Exercise. 
7 

Work. 
3 

Leisure. 
4 

Sleep. 
10 

8  

6 

4 

4 

10 

9  

5 

5 

4 

10 

10.. 

5 

6 

4 

9 

74  Insomnia  and  its   Therapeutics. 


AGE. 
11  

Exercise. 
5 

Work. 
6 

Leisure. 
4 

Sleep. 
9 

12  

5 

6 

4 

9 

13       .    . 

4 

7 

4 

9 

14  

4 

8 

3 

9 

15.. 

4 

8 

3 

9 

Dr.  Dukes,"  of  Rugby,  is  of  opinion  that  boys  under  ten 
years  of  age  require  eleven  hours'  sleep,  and  that  those  under 
thirteen  need  ten  hours  and  a  half  set  aside  for  this  purpose. 
In  his  work  on  "  Health  at  School "  he  writes :  "  The  tendency 
in  schools  is  rather  toward  too  little  than  too  much  sleep;  in 
fact,  in  public  schools  I  think  boys  scarcely  get  enough,  espe- 
cially the  younger  ones;  and  were  it  not  for  the  holidays 
coming  every  twelve  or  thirteen  weeks,  I  do  not  believe  they 
could  do  their  full  share  of  work  and  yet  continue  in  health." 

SHOCK. 

Sleeplessness  from  shock  is  not  so  frequently  met  with  in 
practice  as  to  entitle  it  to  a  very  prominent  place  in  a  work 
on  insomnia ;  but  as  the  facts  connected  with  it  will  serve  to 
illustrate  much  that  is  to  follow,  a  brief  reference  will  be  made 
to  its  effects  upon  the  nervous  system. 

Shock  may  be  caused  by  any  severe  injury  or  excessive 
pain,  or  by  overwhelming  mental  emotion.  It  varies  in  sever- 
ity with  the  nature  and  extent  of  its  cause,  and  affects  some 
individuals  much  more  profoundly  than  others.  The  difference 
depends  upon  the  age,  sex,  habits,  temperament,  and  more  es- 
pecially on  the  stability  of  the  nervous  system.  In  illustration 
of  this,  the  writer  some  years  ago  made  a  post-mortem  exam- 
ination of  the  body  of  a  man  who  had  died  from  extensive 
fracture  of  the  base  of  the  skull  with  hemorrhage.  The  his- 
tory showed  that  he  had  sustained  an  injury  about  12  noon, 
after  which  he  walked  home,  a  distance  of  two  miles.  In  the 
evening  he  visited  a  neighboring  tavern,  where  he  drank 
freely,  and  only  made  casual  reference  to  his  accident.  On 
going  home  he  went  to  bed,  and  died  during  the  night.  In 
contrast  is  a  case  seen  more  recently,  in  which  a  man  lay 
pulseless  for  many  hours,  with  the  heart  beating  inaudibly, 
after  a  trifling  injury  from  a  knife  which  merely  punctured 
the  skin  and  did  not  involve  the  loss  of  a  drachm  of  blood. 


Insomnia  and  its   Therapeutics.  75 

This  difference  in  constitution  well  explains  the  varying-  de- 
grees of  sleep  disturbance  following-  shock. 

Shock  causes  a  rapid  depletion  of  the  brain  and  cutaneous 
surface,  and  interference  with  the  normal  irritability  of  the 
psychical,  motor,  and  sensory  centres;  respiration  and  circu- 
lation are  deranged,  and  the  temperature  of  the  body  is  low- 
ered. These  conditions  combine  to  bring  about  a  partial  par- 
alysis of  the  heart,  and  a  sudden  dilatation  of  the  abdominal 
blood-vessels,  which  are  found  after  death  from  shock  to  be 
enormously  distended,  while  the  vessels  in  the  rest  of  the  body 
are  comparatively  empty.  The  result  of  this  sudden  flushing- 
of  the  vessels  of  the  abdominal  viscera  is  that  less  blood  than 
usual  reaches  the  feebly-acting  heart,  and  the  brain  and  sur- 
face of  the  bod3^  are  rendered  anaemic. 

Sleeplessness,  often  of  a  pronounced  character,  follows; 
and  it  may  continue  during  months  or  years. 

In  many  cases  the  cardiac  and  vaso-motor  centres  never 
seem  to  recover  their  tone,  as  in  the  following  case.  A  healthy 
lady,  aged  sixty-four,  had  the  misfortune  to  fall  upon  the 
pavement,  and  although  she  sustained  no  injury  to  the  bony 
structures,  she  suffered  severely  from  shock  and  died  six  weeks 
afterward,  notwithstanding  every  care.  Throughout  her  ill- 
ness she  had  no  natural  sleep,  vomited  everything  she  swal- 
lowed, and  sweated  profusely ;  in  short,  the  symptoms  were 
all  referable  to  grave  disturbance  in  the  medulla  oblongata. 

Shock  is  not  seldom  the  originating-  cause  of  organic  heart 
disease,  even  when  no  lesion  can  be  diagnosed  at  the  time,  and 
in  many  cases  the  cardiac  disorder  still  further  disturbs  sleep. 
Shock  depending  upon  sudden  mental  perturbation  is  ac- 
countable for  a  certain  percentage  of  all  cases  of  insanity; 
and  it  is  capable  of  arresting  the  menstrual  flow  and  the 
secretion  of  milk  and  of  the  digestive  fluids.  To  severe  cases 
of  shock,  or  to  the  slighter  cases  which  quickly  recover,  we 
shall  not  allude  further.  It  is  with  those  of  medium  severity 
that  we  are  chiefly  concerned — cases  which  recover  speedily 
up  to  a  certain  point,  then  progress  less  satisfactorily,  and 
end  in  an  extremely  protracted  convalescence.  During  their 
progress  the  nervous  system  is  excitable  and  impressionable, 
the  chief,  constant,  and  persistent  symptom  being  insomnia, 
or  imperfect  sleep  disturbed  by  distressing  dreams  from  which 
the  patient  commonly  awakes  in  a  state  of  terror. 


76  Insomnia  and  its   Therapeutics. 

Treatment. — The  most  urgent  indication  at  the  time  is  to 
establish  reaction,  and  to  restore  the  equilibrium  of  the  circu- 
lation without  unduly  exciting  it.  The  shorter  the  duration 
of  the  shock,  and  the  more  complete  the  restoration  of  tone, 
the  less  likelihood  will  there  be  of  sleeplessness  resulting. 
Hence  the  necessity  for  adopting-  adequate  measures  at  the 
onset.  This  is  so  widely  recognized  that  surgeons  invariably 
resort  to  the  use  of  morphine  or  opiates  after  severe  opera- 
tions. 

If  sleeplessness  appears  after  reaction  is  established,  and 
persists  when  the  stage  of  convalescence  is  reached,  there  is 
need  to  administer  remedies  which  will  act  powerfully  upon 
the  enfeebled  centres  in  the  medulla,  so  that  the  cardiac  and 
vascular  tone  may  be  recuperated.  Probably  the  most  pow- 
erful remedy  we  possess  is  strychnine.  Its  stimulant  action 
upon  these  centres  is  slower  in  manifesting  itself  than  when 
sulphuric  ether  is  used,  but  its  effects,  once  secured,  are  much 
more  lasting,  its  elimination  requiring  almost  as  many  hours 
as  ether  does  minutes.  It  is  best  administered  hypodermically, 
and  the  salts  most  suitable  for  the  purpose  are  the  nitrate 
and  the  acid  sulphate.  From  -fa  to  -^  of  a  grain,  repeated 
three  or  four  times  in  twenty-four  hours,  is  usually  sufficient, 
although  these  doses  may  be  cautiously  increased  up  to  y1^  or 
•j^  of  a  grain.  Tincture  of  nux  vomica  may  be  injected  in 
ten-minim  doses  instead  of  strychnine,  but  the  pain  it  causes 
lasts  for  two  or  three  hours.  Either  remedy  can  be  given  by 
the  mouth,  when  it  is  highly  advantageous  to  combine  it  with 
quinine,  for  that  medicine  exerts  an  exceedingly  tonic  influence 
over  the  nervous  and  vascular  systems,  and  is  especially  use- 
ful in  anaemia  of  the  brain  and  medulla  oblongata.  The  fol- 
lowing is  the  formula  the  writer  has  used  for  many  years : 

B  Liq.  strychnin., .     3  i. 

Sulph.  quinin., gr.  xx. 

Acid,  hj'drobrom., 3  vi. 

Infus.  serpentar.,         .        .        .  ad  f  vi. 

M.  Sig.  Take  a  tablespoonful  in  water,  three  times  a  day, 
between  meals. 

Phosphorus,  by  increasing  the  circulation  of  the  brain  and 
acting  as  a  tonic  and  nutrient  to  the  nervous  system,  is  also 
found  useful  in  these  cases,  and  is  best  given  in  doses  of  -^  of 


Insomnia  and  its  Therapeutics.  jj 

a  grain  three  times  a  day,  the  elixir  of  phosphorus  (Martin- 
dale's)  and  the  perles  of  phosphorated  oil  being  good  forms 
for  its  administration. 

Calabar  bean  has  been  suggested,  but  of  its  use  in  this  con- 
dition the  writer  has  no  experience. 

It  is  usually  necessary  to  resort  to  the  use  of  hypnotics  for 
a  few  nights  for  the  purpose  of  securing  sleep,  which  is,  par 
excellence,  the  most  potent  recuperative  agent  of  all;  and  for 
this  purpose  opium,  or  its  alkaloid  morphine,  is  especially  in- 
dicated, as  it  is  in  all  anaemic  states  in  which  insomnia  is  a 
prominent  symptom. 

The  following  is  a  useful  pill : 

5  Ext.  opii,      .        .        .  .        .        .  gr.  ss. 

Ext.  belladon., gr.  £. 

Pulv.  digital.,       '. gr.  i. 

Pulv.  camphor., gr.  ij. 

Ft.  pil.  i.     Sig.  Take  at  bedtime. 

Morphine  administered  hypodermically  in  doses  of  -fa  to  \ 
of  a  grain,  in  most  cases,  insures  a  good  night's  rest.  Of  the 
many  preparations  of  morphine,  the  writer  thinks  the  tar- 
trate  the  best  for  general  use,  on  account  of  its  solubility.  It 
is  often  advantageous  to  combine  it  with  -j-J-g-  of  a  grain  of 
atropine  sulphate,  which  checks  the  tendency  to  vomiting 
which  morphine  so  frequently  causes  immediately  after  it  is 
injected,  while  it  appears  to  augment  the  hypnotic  properties 
of  morphine.  Atropine  alone  is  a  valuable  therapeutic  remedy 
in  all  cases  of  reflex  cardiac  inhibition,  such  as  obtains  in  shock. 

The  food  should  be  nourishing  and  easily  digested,  and  the 
bowels,  if  constipated,  regulated  by  some  mild  laxative,  such 
as  aloes  combined  with  belladonna  or  henbane.  Alcohol  in 
the  most  suitable  form  must  be  allowed,  so  long  as  it  aids 
digestion;  and  everything  that  is  likely  to  inspire  the  patient 
with  confidence  and  hope  must  be  sedulously  considered  and 
adopted. 

DEPRESSING  EMOTIONS. 

Prolonged  depressing  emotions,  such  as  anxiety,  grief, 
worry,  etc.,  are  frequent  sources  of  insomnia,  and  though  usu- 
ally classed  with  overwork,  the  symptoms  of  which  they 
closely  resemble,  they  differ  in  certain  important  respects,  one 


78  Insomnia  and  its   Therapeutics. 

being  that  overwork  may  cause  sleeplessness  to  arise  in  the 
hopeful  and  vigorous,  while  worry  is  always  more  or  less  as- 
sociated with  hopelessness.  From  the  earliest  times  mental 
perturbations  have  been  recognized  as  inimical  to  sleep.  Hip- 
pocrates notes  as  a  fact  that  "the  insomnolency  is  connected 
with  sorrow." 

Burton  gi-ves  the  following-  quotations  from  Crato  which 
point  in  the  same  direction :  "  Grief,  cares,  expectations,  anx- 
ieties, great  businesses,  and  all  violent  perturbations  of  the 
mind  must  be  in  some  source  gratified  before  one  can  hope  for 
any  good  repose.  .  .  .  He  that  is  in  suspense,  fear,  or  in  any 
way  troubled  in  mind  can  never  rest  at  night." 

The  effects  of  such  emotions  are  truly  credited  with  being 
more  baneful  than  those  of  overwork,  with  which  they  are 
often,  though  not  necessarily,  associated;  and  they  appear 
to  depend  on  a  combination  of  circumstances.  Emotion,  of 
whatever  form,  implies  activity  in  the  emotional  regions  of 
the  brain.  In  worry  these  parts,  from  being  in  constant 
function,  get  into  the  same  pathological  condition  of  exhaus- 
tion and  congestion  which  we  described  as  resulting  in  the 
psychical  sites  from  overwork.  Upon  this  fact  is  based  the 
physiologically  true  saying  that  "fifty  worries  are  better 
than  one  worry,"  for  in  the  former  case  the  sites  of  activity 
are  altered  from  time  to  time,  and  the  strain,  being  distributed 
over  a  wider  area,  is  better  borne  than  when  the  mental  dis- 
turbance is  due  to  one  never-changing  cause.  This,  however, 
is  not  the  whole  case,  for  the  effects  of  mental  emotions  upon 
the  sympathetic  nervous  system  require  to  be  taken  into  ac- 
count. If  they  are  pleasurable,  these  centres  are  stimulated 
to  greater  activity,  and  this,  being  reflected  along  the  whole 
circulatory  apparatus,  gives  rise  to  feelings  of  comfort  and 
exhilaration.  If,  on  the  contrary,  these  emotions  are  of  an 
opposite  kind,  the  effect  on  the  nervous  centres  is  such  as  to 
cause  circulatory  modifications  of  an  atonic  character,  which 
are  followed  by  general  depression  and  mental  suffering. 
These  vascular  changes  are  due  to  inhibition  of  the  cardiac 
and  vaso-motor  centres  similar  to  that  occurring  in  shock, 
but  more  gradual  and  insidious  in  their  onset,  as  was  well 
expressed  by  Dr.  Hughlings  Jackson  in  the  following  words: 
"Fright  and  anxiety — which  latter  is  only  fright  spread  out 
thin."  This  inhibition  leads  to  defective  innervation  of  the 


Insomnia  and  its  77ierapeutics.  79 

heart  and  gastro-intestinal  canal,  which  brings  in  its  train 
cardiac  derangements  and  digestive  troubles,  with  consequent 
disordered  nutrition.  In  most  cases  vascular  tension  is  re- 
laxed, and  in  all  sleep  is  seriously  interfered  with,  being  either 
absent  altogether,  or  imperfect,  and  disturbed  by  nightmare 
and  dreams.  The  conditions,  in  short,  brought  about  by  de- 
pressing emotions  are  similar  to  those  which  result  from  over- 
work, with  a  modified  amount  of  shock  superadded. 

The  effects  of  worry,  etc.,  expend  themselves  upon  the 
feeblest  portion  of  the  nervous  textures,  and  consequently  are 
most  frequently  seen  in  sj^mpathetic  persons  whose  emotional 
centres  are  weak  and  impressionable.  They  are  often  devel- 
oped in  severe  forms  in  females,  and  are  always  modified  by 
age,  temperament,  general  health,  and  the  source  of  the 
worry.  A  patient  so  afflicted  presents  a  downcast  and  de- 
jected aspect,  the  face  is  drawn  and  haggard,  the  eyes  are  dull 
and  expressionless,  while  vision  is  dim,  and  the  pupils  react  to 
light  sluggishly. 

Mental  depression  and  misery  are  complained  of,  with 
headache,  confusion  of  thought,  loss  of  memory,  lassitude,  and 
disinclination  for  exertion.  The  heart  is  weak  and  palpitates, 
and  not  infrequently  the  functional  derangement  ends  in  or- 
ganic change,  the  explanation  of  which  is  sufficiently  obvious. 
Worry,  as  has  already  been  hinted,  consists  of  a  series  of 
small  shocks,  following  upon  each  other  more  or  less  rapidly, 
and  at  each  shock,  small  though  it  be,  the  heart  is  temporary 
inhibited  and  fails  to  expel  its  contents  thoroughly,  so  that  at 
the  next  systole  it  has  to  deal  with  a  larger  amount  of  blood 
than  usual.  The  consequence  is  that  the  weakened  muscular 
walls  yield  under  the  strain,  and  dilatation  occurs. 

The  appetite  is  poor,  and  the  patient  suffers  from  flatu- 
lence, acidity,  heartburn,  and  constipation  or  relaxation  of  the 
bowels. 

The  urine  may  contain  phosphates  in  excess,  or  oxalate  of 
lime,  or  traces  of  sugar  or  albumin.  It  is  often  copious  and 
of  low  specific  gravity,  and,  in  fact,  presents  all  the  character- 
istics of  the  urine  of  chronic  Bright's  disease,  of  which  worry 
is  sometimes  the  only  recognizable  cause.  The  patient  usu- 
ally loses  flesh  quickly,  in  consequence  of  defective  metabolism, 
and  if  his  condition  is  not  ameliorated  he  gradually  merges 
into  the  more  pronounced  condition  of  neurasthenia. 


8o  Insomnia  and  its  Therapeutics. 

We  may  here  remark  in  passing-  that  the  effects  of  grief 
have  frequently  been  studied  in  animals,  notably  in  dogs;  and 
cases  have  been  recorded  in  which  they  proved  fatal. 

Treatment. — It  is  important  in  the  first  place  to  ascertain 
the  source  and  nature  of  the  worry,  so  that  if  it  has  its  origin 
in  some  bodily  ailment,  such  as  varicocele,  the  cause  may  be 
removed.  In  many  cases,  however,  the  patient  seeks  advice 
for  insomnia,  or  dyspepsia  with  disturbed  sleep,  and  so  far 
from  hinting-  that  it  is  due  to  grief,  he  seeks  to  conceal  his 
sorrow,  and  it  requires  delicacy  and  tact  to  overcome  reti- 
cence and  to  obtain  a  frank  confession  of  the  trouble. 

If  it  is  a  monetary  anxiety,  the  physician  might  prove  him- 
self a  magician  if,  instead  of  writing-  a  prescription,  he  could 
give  an  order  upon  his  banker  for  the  needed  amount.  Un- 
fortunately few  physicians  have  it  in  their  power  to  do  so,  and 
those  who  have  do  not  appear  to  think  of  it!  If  it  is  due  to 
the  strain  of  over-speculation  or  gambling1,  which  keeps  the 
cerebral  cells  ever  on  the  qui  vive,  watching-  constantly  for 
telegrams,  until  every  ring  at  the  bell  acts  like  a  shock,  hop- 
ing and  fearing-  by  turns,  little  good  can  be  done  until  the  ill- 
used  cells  are  released  from  their  bondage  of  uncertainty  and 
suspense.  The  physician's  powers  are  likewise  limited  in  cases 
of  anxiety  about  personal  health,  or  that  of  friends,  or  when 
grief  depends  upon  bereavement,  or,  still  worse,  upon  living- 
sources  of  sorrow.  There  is  one  thing,  however,  that  the 
physician  has  in  his  power — he  can  bring  a  clear  and  unbiassed 
mind  to  bear  upon  the  case,  and  by  judicious  advice  and  coun- 
sel he  may  go  a  long  way  toward  putting-  the  sufferer  into  a 
condition  for  bearing  his  trials  manfully.  He  may  also  help 
him  greatly  with  his  burden  by  securing  repose  for  his  wearied 
brain  and  by  bracing  his  heart  and  arterial  system. 

In  cases  in  which  the  general  health  is  not  greatly  impli- 
cated, the  best  of  all  remedies  is  work  of  a  good  and  hopeful 
kind,  perseveringly  maintained.  It  calls  the  psychical  centres 
into  operation,  and  by  withdrawing  the  excess  of  blood  from 
the  emotional  centres,  the  latter  gradually  obtain  the  repose 
they  so  much  require,  and  their  hypersensitive  condition, 
which  responded  to  the  most  trifling  impressions,  soon  be- 
comes less  marked.  Many  a  man  has  reason  to  be  thankful 
for  the  blessing  of  work  which  enables  him  to  bury  his  worry, 
for  the  time  being,  in  oblivion.  If  work  does  not  form  a  part 


Insomnia  and  its  Therapeutics.  81 

of  his  every-day  life,  it  is  essential  that  he  should  find  some 
"healthful  and  wise  enterprise  in  which  he  can  engross  himself. 
The  alternation  from  idleness  to  healthy  employment  is  the 
best  and  the  only  physiological  change  that  he  can  obtain. 
All  that  was  written  on  the  subject  of  a  second  occupation, 
regimen,  diet,  stimulant,  exercise,  change  of  scene,  when  dis- 
cussing the  treatment  of  overwork,  and  much  of  what  has  still 
to  be  added  regarding  the  treatment  of  neurasthenia,  might 
be  repeated  here,  but  to  these  remarks  the  reader  is  referred. 

In  pronounced  cases,  the  stimulating  effects  of  the  morn- 
ing bath  must  be  proportioned  to  the  strength  of  the  patient. 
The  more  robust  may  employ  cold,  but  the  weakly  should  use 
tepid  or  warm  water,  exposing  the  body  during  the  process  as 
little  as  possible,  and  employing  the  flesh-brush  freely.  The 
Turkish  bath  and  sitz  bath  are  both  useful  in  these  conditions, 
and  if  the  Turkish  bath  is  advised,  the  patient  should  be 
recommended  to  "  finish  "  with  the  spinal  douche. 

At  night  besides  douching  the  head  with  tepid  water,  and 
using"  the  other  means  already  referred  to,  several  applications 
may  be  tried  to  promote  sleep,  among  them  sponging  the 
nape  of  the  neck  and  spine  with  very  hot  water,  or  merely 
rubbing  the  spine  firmly  with  a  warm  hand  until  redness  of 
the  skin  is  produced.  Kneading  and  rubbing  the  abdomen 
appears  to  produce  hj^persemia  of  its  contents  with  a  corre- 
sponding ansemia  of  the  brain.  This  may  perhaps  simulate 
in  a  very  moderate  degree  the  results  obtained  by  Goltz, 
who,  by  smartly  tapping  on  the  belly-  of  a  frog,  drew  into  its 
abdominal  vessels  the  most  of  the  blood  in  the  body,  by  para- 
lyzing the  splanchnic  nerves. 

A  mustard  plaster  applied  over  the  abdomen  has  a  most 
soothing  influence,  causing  contraction  of  the  blood-vessels  of 
the  pia  mater,  which  is  favorable  for  sleep.  It  should  not  be 
kept  on  longer  than  ten  or  twelve  minutes,  else  it  may  cause 
so  much  local  irritation  as  to  defeat  the  end  in  view ;  nor  must 
it  be  applied  over  the  region  of  the  heart,  as  the  stimulation 
of  that  organ  is  inimical  to  sleep.  Dr.  George  Keith,  who 
formerly  practised  in  Edinburgh,  mentioned  to  the  writer  that 
in  some  cases  it  did  not  act  so  beneficially  if  placed  over  the 
lower  part  of  the  abdomen ;  a  clinical  observation  which  he 
could  not  explain.  This  fact  militates  against  the  simple 
theory  of  a  transposition  of  blood  from  the  cerebral  to  the 


82  Insomnia  and  its  Therapeutics. 

abdominal  blood-vessels.  When  the  plaster  is  taken  off,  the 
part  should  be  sponged  with  warm  water  to  remove  any  ad- 
herent particles  of  mustard. 

The  hot  foot-bath  at  night  acts  in  some  as  a  hypnotic.  In 
fairly  nourished  cases  quinine  and  strychnine_are,  as  in  shock, 
useful  and  powerful  agents. 

3  Sulph.  .quinin., gr.  i. 

Sulph.  strychnin.,        .        .        .        .        .    gr.  ^. 

Ext.  gentian., q.  s. 

Ft.  pil.  i.     Sig.  Take  one  before  meals  thrice  daily. 

Arsenic  may  in  some  cases  be  combined  with  these  reme- 
dies, for  as  an  alterative  and  tonic  it  has  few  rivals,  strength- 
ening and  calming  the  nervous  system. 

IJ  Tinct.  quinin., f  i. 

Liq.  strychnin., 3  i. 

Liq.  arsen.  sodii,      .        .        .  3  ss.  vel  3  i. 

Infus.  serpentar., ad  3  vi. 

M.  Sig.  Take  a  tablespoonful  in  water,  after  meals,  thrice 
daily. 

If  the  heart  is  irritable,  and  there  is  great  relaxation  of 
vascular  tension,  digitalis  must  be  added. 

5  Tinct.  digital., 3  ij. 

Liq.  strychnin., 3  i. 

Liq.  arsen.  sodii,      .        .        .  3  ss.  vel  3  i. 

Infus.  calumb., ad  §  vi. 

M.  Sig.  Take  a  tablespoonful,  in  water,  three  times  a 
day  after  meals. 

In  the  anaemic  and  badly  nourished,  when  the  digestive 
powers  will  bear  the  use  of  iron,  few  remedies  surpass  the 
syrup  of  the  phosphates  of  quinine,  strychnine,  and  iron 
(Easton's  syrup),  in  doses  of  one  teaspoonful  in  water  after 
meals  three  times  a  day.  Iron  may  also  be  prescribed  in  a 
pill. 

$  Ferri.  redact.,       .        .        .        .        .        .    gr.  iij. 

Sulph.  quinin.,      .    ' gr.  i. 

Ext.  nucis  vomic., gr.  ss. 

Glycer.  tragacanth., q.  s. 

Ft.  pil.  i.     Sig.  Take  one  after  meals  three  times  a  day. 
Notwithstanding  all  that  has  been  written  against  phos- 


Insomnia  and  its  Therapeutics.  83 

phorus  and  its  efficacy,  the  writer  has  reason  to  be  satisfied 
with  the  results  he  has  obtained  from  it;  besides  the  elixir 
and  perles,  it  may  be  given  in  the  form  of  the  phosphide  of 
zinc  in  a  pill  containing1  from  gr.  -fa  to  gr.  |.  It  may  also  be 
prescribed  in  combination  with  quinine  and  strychnine,  which 
emphasize  its  effects. 

Iji   Phosphid.  zinc.,    ....    gr.  -^  vel  gr.  ss. 

Sulph.  quinin., gr.  i. 

Ext.  nucis  vomic., gr.  ss. 

Ext.  gentian., q.  s. 

Ft.  pil.  i.     Sig.  Take  one  after  meals  thrice  daily. 

When  these  remedies  and  regimen  fail  to  induce  sleep,  it 
becomes  absolutely  necessary  to  resort  to  the  use  of  hypnotics, 
for  no  appreciable  improvement  can  accrue  until  sleep  recu- 
perates the  nervous  system.  It  is  only  when  the  distressed 
mind  is  oblivious  to  its  sorrows  that  the  cerebral  cells  can  re- 
cruit their  tone.  For  this  purpose  chloral  hydrate  may  be 
prescribed,  as  it  is  probably  one  of  the  most  powerful  pure 
hypnotics  we  possess,  though  its  employment  is  so  fraught 
with  risk  that  its  use,  except  under  medical  advice,  is  much 
to  be  deprecated.  The  number  of  deaths  that  have  followed 
its  indiscriminate  use  warrants  this  warning.  Its  administra- 
tion should  not,  under  any  circumstances,  be  long  persevered 
in,  on  account  of  its  depressing  effects.  Its  use  in  the  cases 
of  neurotic  patients  should  be  carefully  considered,  they  being 
very  liable  to  acquire  the  chloral  habit,  to  which  we  shall 
refer  hereafter.  It  is  best  given  in  doses  of  20  to  25  grains 
with  syrup  of  tolu  at  bedtime,  and  it  can  be  repeated  in  an 
hour  if  it  is  required.  Its  efficacy  is  augmented  by  potassium 
bromide. 

5  Hydrat.  chloral.,  .        .        .        .     3ij.  vel  3iiss. 

Bromid.  potass.,     .        ,        .        .        .        .    3  i. 

Syr.  tolu.,      .        .        .       „        .        .        .3  iss. 

Mist,  camph., 3  xivss. 

M.  Sig.  Take  one  half  at  bedtime,  and  the  other  half  in 
an  hour  if  required. 

In  the  weakly,  when  chloral  hydrate  is  deemed  to  be  too 
depressing,  paraldehyde  often  answers  well.  The  usual  dose 
is  said  to  be  from  15  to  50  grains;  to  insure  sleep  45  to  50 
grains  »re  required.  Some  think  that  from  3  i.  to  3  ij.  is  the 


84  Insomnia  and  its   Therapeutics. 

proper  dose.    The  following1  formula  has  afforded  the  writer 
excellent  results : 

B  Paraldehyd.,  .    TH,  xlv.  vel  in,  lx. 

Syr.  torn.,     .......       3  i. 

Inf us.  caryophyll., 3  xi. 

M.    Sig-.  Take  at  bedtime. 

Like  all  other  hypnotics,  the  system  becomes  tolerant  to 
its  use;  it  should  not  therefore  be  administered  for  more  than 
six  or  eight  nights  consecutively. 

Bromidia,  though  a  proprietary  medicine,  has  in  several 
instances  been  found  reliable,  in  drachm  doses  given  in  syrup 
and  water  at  intervals  of  an  hour  until  sleep  is  induced. 

Sulphonal  upon  several  occasions  has  yielded  the  writer 
most  excellent  results,  so  much  so  that  he  believes  this  remedy 
to  be  a  real  addition  to  the  list  of  hypnotics.  He  gives  it  in 
doses  varj'ing  from  20  to  30  grains  made  into  an  electuary 
with  honey,  two  hours  before  bedtime,  and  directs  that  warm 
water  or  very  weak  toddy  should  be  taken  shortly  afterward 
to  promote  its  solution  in  the  stomach. 

Urethane  and  hypnone  have  both  been  prescribed  with 
good  effect,  but  they  seem  to  be  less  reliable  than  the  hypno- 
tics already  mentioned. 

Dlosely  allied  to  the  conditions  caused  by  depressing-  emo- 
tions is  that  state  of  mind  produced  so  frequently  in  children 
by  fear.  Fear  is  merely  a  modification  of  fright  and,  like  it, 
gives  rise  to  nervous  shock  with  its  usual  accompaniments. 
Some  children  are  naturally  timid  and  afraid  to  remain  by 
themselves,  or  to  go  to  bed  in  the  dark.  When  a  strain  of 
this  description  is  put  upon  them,  the  emotional  centres  tend 
to  become  active  and  hypersemic,  while  the  volitional  centres 
are  dominated,  and  loss  of  voluntary  control  is  the  result. 
Such  patients  require  careful  consideration  and  management ; 
bullying-  and  jeering  only  make  matters  worse,  while  a  light 
in  the  bedroom  or  the  presence  of  some  one  within  call  in- 
spires confidence,  and  allows  the  emotional  centres  to  calm 
down,  and  natural  sleep  to  ensue.  With  kindly  treatment 
and  encouragement  the  dread  of  the  unknown  disappears  with 
advancing  years  and  increasing  strength.  As  regards  thera- 
peutic measures,  the  bromides  will  be  found  the  most  suita- 
ble as  well  as  the  most  efficacious.  Sulphonal  has  been  found 
worthy  of  trial  in  these  cases. 


CHAPTER  IV. 

INSOMNIA  DEPENDING  UPON  AFFECTIONS  OF  THE 
NERVOUS  SYSTEM— Continued. 

NEURASTHENIA. 

CEREBRAL  and  spinal  neurasthenia  are  names  applied  to 
certain  obscure  conditions  which  are  the  most  common  of  all 
causes  of  insomnia.  They  are  characterized  by  irritability 
and  exhaustion  of  the  brain  or  spinal  cord,  as  the  symptoms 
are  able  to  be  referred  to  either  of  those  centres  respectively. 
In  many  cases  they  indicate  that  both  are  implicated.  The 
symptoms  differ  very  considerably  in  severity  in  various  cases, 
amounting  in  some  to  mere  "  nervousness "  and  in  others  to 
profoundly  marked  neurasthenia. 

The  causes  are  of  the  most  variable  kind,  and  the  sufferers 
have  their  symptoms  biassed  in  a  remarkable  way  by  their 
temperament  and  mental  and  physical  development,  as  modi- 
fied by  education,  self-training1,  habits,  and  social  position.  It 
occurs  mostly  in  those  who  have  an  hereditary  tendency  to 
nervous  diseases,  and  who  possess  a  neurotic  temperament. 
It  affects  males  more  frequently  than  females,  especially  males 
in  early  middle  life  belonging*  to  the  wealthier  classes  who 
may  previously  have  been  robust  and  muscular  men. 

The  symptoms  follow  in  the  train  of  many  circumstances 
which  tend  to  produce  nervous  prostration.  It  is  a  disease  of 
fatigue,  in  which  the  expenditure  of  nervous  energy  has  ex- 
ceeded the  recuperative  powers  of  the  economy.  The  mental 
causes  include  prolonged  mental  toil,  protracted  excitement, 
depressing  emotions,  such  as  worry,  grief,  anxiety,  ungratified 
ambition  or  desires,  etc.  The  physical  causes  embrace  great 
and  prolonged  bodily  fatigue,  all  excesses,  or  discharges,  the 
immoderate  use  of  alcohol  and  tobacco,  living  under  unhealthy 
conditions,  and  food  deficient  in  quality  and  quantity.  The 
symptoms  may  appear  in  the  convalescence  from  severe  dis- 
eases, fevers,  anaemias,  cachexias,  and  in  the  disorders  of  nutri- 
• 


86  Insomnia  and  its   Therapeutics, 

tion.  In  females,  from  drains  upon  the  system,  too  frequent 
pregnancies,  and  over-suckling1.  In  the  young  adult  from 
defective  nutrition,  badly-balanced  mental  work,  and  physical 
over-training. 

In  the  great  majority  of  cases,  these  causes  have  been  as- 
sociated with  insomnia  for  lengthened  periods  of  time,  an  ag- 
gravation which  has  accelerated  the  breakdown.  The  first 
indications  of  the  exhaustion  or  prostration  are  referred  to 
the  brain  and  nervous  system,  which  in  their  turn  display 
their  enfeeblement  by  signs  of  irritability  and  instability  in 
the  whole  nervous  apparatus,  including  the  vaso-motor  centres. 
The  whole  body  is  made  to  feel  the  lack  of  efficient  inner  va- 
tion  (the  heart,  digestive  organs,  etc.),  and  this,  in  the  course 
of  time,  leads  to  deficient  and  imperfect  nutrition,  which 
vastly  adds  to  the  exhaustion.  The  symptoms  belong  to  the 
different  organs  and  viscera.  There  is  a  profound  sense  of 
the  loss  of  energy  and  power,  with  failure  of  mental  vigor  and 
memory,  accompanied  by  a  feeling  of  depression  (mental 
pain)  and  despondency.  The  power  of  will  is  enfeebled,  lead- 
ing to  uncertainty  of  temper  and  unreasoning  obstinacy.  At 
all  times  irritable,  vacillating,  and  self-conscious,  these  individ- 
uals dwell  watchfully  upon  various  sensations,  and  with  ever- 
increasing  introspection  become  timid,  and  live  in  the  constant 
dread  of  the  unknown  happening.  Every  little  trouble  ap- 
pears to  overwhelm  them.  Some  are  afraid  to  be  left  alone  in 
a  room,  or  to  travel  by  rail;  others  have  a  dread  of  fire,  or 
that  they  will  lose  their  reason,  or  become  the  victims  of  some 
deadly  disease.  They  complain  of  swimming  in  the  head, 
headache  occipital  in  character  and  often  accompanied  by 
tenderness  of  the  scalp,  giddiness,  uncertainty  in  movements, 
noises  in  the  ears,  and  neuralgic  pains  in  various  parts  of  the 
body,  dimness  of  vision,  intolerance  to  strong  light,  and  often 
of  specks  floating  before  the  eyes,  while  sighing  and  yawning 
are  frequently  present.  The  pupils  may  be  dilated,  and  the 
dimness  of  vision  may  depend  upon  errors  of  refraction,  which 
in  health  could  be  overcome  by  muscular  effort,  but  which  the 
exhaustion  renders  impossible.  In  other  cases  no  ascertain- 
able  ocular  lesion  exists,  and  the  weakness  of  sight  is  ex- 
tremely variable,  being  made  worse  by  fatigue,  and  improved 
by  food  and  stimulant;  it  is  worst  in  the  morning  and  best  in 
the  evening.  . 


Insomnia  and  its   Therapeutics.  87 

In  the  cases  where  the  symptoms  are  chiefly  referable  to 
the  spinal  cord,  besides  suffering1  from  some  of  the  foregoing1 
symptoms,  these  patients  complain  of  utter  prostration  greatly 
exaggerated  by  even  slight  exertion,  accompanied  by  stiff  ness, 
cramps  and  pains  in  the  muscles  (which  are  probably  due  to 
the  coagulation  of  the  myosin),  most  marked  after  resting 
for  a  short  time  and  subsequent  to  some  exercise;  and  also  of 
muscular  twitchings  and  fibrillar  tremblings — the  physiologi- 
cal signs  of  fatigued  muscular  fibre. 

Pain  is  referred  to  the  lower  part  of  the  spine  or  to  the 
nape  of  the  neck,  and  is  due  in  many  cases  to  spinal  anaemia, 
or  hyperaemia,  both  of  which  conditions,  causing  disordered 
nutrition  of  the  nerve  cells,  give  rise  to  similar  symptoms. 
These  symptoms  vary  in  different  cases  according  to  the  por- 
tion of  the  cord  affected. 

Sensations  of  numbness,  formication,  or  pins  and  needles, 
are  invariably  more  or  less  decidedly  present.  The  upper  ex- 
tremities may  participate  in  the  weakness,  and  in  some  cases 
there  are  pseudo-spasms  of  the  hand  and  fingers,  associated 
with  more  or  less  persistent  numbness.  Usually  the  weak- 
ness is  mainly  referred  to  the  legs,  the  patient  observing,  "  If 
I  had  to  fight,  I  should  have  to  sit  down  to  do  so."  The  patel- 
lar  tendon  reflex  is  sometimes  exaggerated,  and  occasionally 
the  ankle  clonus  may  be  elicited  in  a  faint  degree,  though  this 
varies  from  day  to  day,  and  as  recovery  takes  place  excita- 
bility disappears. 

Neurasthenics  are  dyspeptic,  the  digestive  derangements 
depending  upon  the  defective  innervation  of  the  various  pro- 
cesses. The  appetite  may  be  impaired,  but  in  the  majority  of 
cases  it  is  increased,  and  there  is  a  craving  for  food  and  stimu- 
lant which  for  a  time  dispels  the  symptoms.  Flatulence,  con- 
stipation, or  looseness  of  the  bowels,  uneasy,  even  painful 
sensations,  and  pulsations  in  the  abdomen,  are  frequently 
prominent  and  troublesome  symptoms.  One  patient  compared 
his  abdominal  discomfort  to  the  contents  being  grasped  by  a 
strong  claw  or  vice.  These  dyspeptic  troubles  aggravate  the 
mental  gloom,  and,  combined,  they  lead  to  functional  disorders 
of  the  liver. 

There  is  cardiac  weakness,  the  heart's  sounds  and  impulse 
are  feeble,  pulse  weak  and  compressible;  although  often  slow, 
it  is  readily  quickened  by  exertion.  There  are  abnormal 


88  Insomnia  and  its  Therapeiitics. 

sensations  in  the  region  of  the  heart,  with  uneasy  pain  causing 
faintness;  the  patient  often,  besides  sighing,  complains  that 
he  cannot  draw  a  long  breath,  or  "  get  to  the  bottom  of  it." 
In  some  cases  there  is  weakness  or  irritability  of  the  bladder, 
and  the  urine  may  contain  oxalate  of  lime  crystals,  phos- 
phates in  excess,  urates,  uric  acid,  and  occasionally  traces  of 
sugar,  and  sometimes  albumin  with  a  deficient  excretion  of 
urea. 

These  patients  are  extremely  susceptible  to  draughts  and 
to  changes  of  temperature;  cool,  bright,  and  bracing  weather 
suits  them  best,  their  lassitude  and  disinclination  for  exertion 
being  much  increased  in  warm,  close  weather. 

The  personal  appearance  is  variable;  in  some  it  is  remark- 
ably little  altered;  others  look  haggard  and  worn  out;  most 
look  older  than  their  years.  The  hair  is  dry  and  lacks  lustre, 
tends  to  fall  off  and  to  become  gray;  the  teeth  begin  to  decay; 
the  skin  is  either  clammy  and  moist  or  dry  and  scaly,  and 
quickly  loses  the  suppleness  of  health.  In  young  adults  the 
symptoms  are  accompanied  by  a  listlessness  and  apathy 
which  is  very  characteristic.  If  it  arises  from  over-training, 
it  is  ushered  in  by  a  loss  of  m  uscular  and  nervous  energy,  loss 
of  pluck,  headache,  and  feverishness. 

The  two  symptoms,  however,  which  demand  and  receive 
most  attention  are,  first,  a  loss  of  flesh  which  is  quite  remark- 
able, being  as  great  as  that  which  occurs  in  connection  with 
organic  disease,  and,  second,  sleeplessness,  which  is  a  distress- 
ing and  pronounced  feature  in  probably  three-fourths  of  all 
cases.  It  is  probably  due  mainly  to  exhaustion  and  irritabil- 
ity of  the  nervous  centres  depending  upon  malnutrition,  and 
in  a  less  degree  to  circulatory  derangements  arising  from  the 
impressionability  of  the  vaso-motor  centres.  Patients  usually 
fall  asleep  soon  after  going  to  bed,  to  awake  in  one,  two,  or 
three  hours,  and  to  remain  awake  for  the  rest  of  the  night;  or 
if  they  get  to  sleep  again,  it  is  only  for  an  hour  or  so  before 
the  time  of  arising,  and  their  doze  is  disturbed  and  uneasy. 
During  their  wakefulness,  apparently  from  irritability  and 
congestion  of  the  motor  centres,  they  are  restless,  fidgety, 
and  occasionally  require  to  get  up  and  wander  about.  In 
almost  all  cases  they  rise  in  the  morning  more  weary  than 
when  they  went  to  bed.  Many  patients  are  accustomed  to 
estimate  the  amount  of  sleep  they  get  by  their  feelings  of  re- 


Insomnia  and  its  Therapeutics.  89 

cuperation  the  following-  day;  sometimes  they  say,  "I  must 
have  got  more  sleep  than  I  thought." 

Besides  being  urgent  symptoms,  the  emaciation  and  in- 
somnia have  a  special  prognostic  value.  All  improvement 
being  preceded  by  a  gain  in  weight,  a  relapse  may  equally  be 
predicted  from  a  loss  of  flesh.  Dr.  Beard  writes :  "  So  one  of 
the  first  signs  of  improvement,  the  earliest  evidence  that  the 
treatment  is  doing  the  work  designed,  is  sleep  sounder  and 
more  of  it,  less  troubled  dreaming,  less  nightmare,  less  rest- 
lessness/' There  cannot  certainly  be  any  amelioration  of  the 
symptoms  without  increased  nutrition  and  sleep. 

The  onset  of  the  symptoms  is  usually  gradual,  amounting1 
at  first  only  to  a  depression  or  lowness  of  spirits,  from  which 
the  patient  recovers  to  relapse  again  into  a  condition  in  which 
they  are  more  pronounced.  When  the  symptoms  are  marked 
they  may  resist  treatment  for  lengthened  periods,  even  3rears, 
but  under  proper  conditions  the  prognosis  is  favorable. 

Relapses  are  frequent;  patients  impatient  for  speedy  re- 
sults cannot  obtain  them;  the  recuperative  process  is  always 
slow  and  gradual. 

Treatment. — Dr.  Clifford  Allbutt,  in  his  third  Gulstonian 
lecture  on  visceral  neuroses,  in  1884,  spoke  some  truths  which 
are  particularly  applicable  here:  "The  beginning-  of  all  suc- 
cessful treatment  must  be  to  convince  the  patient  of  the  true 
nature  of  his  malady.  Now,  your  neurotic  is  one  who  has  no 
reserve.  This  want  is  probably  due  to  a  congenital  instability 
of  nerve,  showing  itself  as  waste,  so  ceaseless,  that  the  reserve 
once  dissipated  is  never  reaccumulated.  This  reserve  may 
have  been  spent  in  beneficent  activities,  or  it  may  have  been 
dissipated  in  fidgets,  fretfulness,  or  shrewishness;  in  sleepless- 
ness, in  anxiousness,  or  in  pain,  according  to  the  quality  of 
the  person.  We  are  disposed  to  forget  that  the  silent  work 
of  nutrition  uses  more  force  perhaps  than  many  people  expend 
in  their  neuro-muscular  life;  hence  the  early  failure  of  the  di- 
gestive resources  in  neurotics,  hence  the  fall  of  the  balance  of 
nutrition  below  the  needs  even  of  a  controlled  expenditure. 
We  know  that  g-ood  nutrition  is  a  chief  condition  of  steady 
work,  good  temper,  and  self-control;  we  know,  too,  that  to 
trade  daily  only  upon  the  supplies  of  the  day  is  to  court  col- 
lapse ;  we  must  have  more  brain,  more  spinal  marrow,  more 
liver,  more  kidney  than  we  want  for  the  day."  This  powerful 


90  Insomnia  and  its  Therapeutics. 

and  explicit  statement  indicates  the  end  to  which  the  treat- 
ment must  be  designed  and  directed. 

The  causation  of  the  neurasthenic  state  must  be  diligently 
investigated,  with  the  view  of  discovering  the  faulty  physio- 
logical arrangements  in  the  patient's  life  that  have  brought 
it  about,  that  they  may  be  amended;  and  this  is  the  more 
urgently  called  for  when  it  is  realized  that  the  diagnosis  of 
the  affection  can  only  be  arrived  at  per  viam  exclusionis. 
When  the  condition  has  been  induced  by  excessive  mental 
work,  shock,  depressing  mental  emotions,  or  prolonged  excite- 
ment, the  reader  is  referred  to  the  preceding  chapter,  which 
treats  of  these  subjects,  and  which  must  be  taken  in  connec- 
tion with  what  is  to  follow. 

When  it  has  been  caused  by  prolonged  bodily  fatigue, 
physical  over-training,  sexual  excesses  or  masturbation,  these 
indiscretions  must  be  most  strenuously  interdicted. 

If  it  has  resulted  from  excessive  drains  on  the  system,  as 
in  spermatorrhoea,  leucorrhoea,  menorrhagia,  or  over-lactation, 
these  exhausting  influences  require  special  treatment  that 
they  may  be  remedied.  Uterine  derangements  must  be  recti- 
fied; unhealthy  surroundings  abandoned;  disorders  of  nutri- 
tion and  digestion  critically  inquired  into  and  relieved;  and 
in  each  and  every  case  sleep  must  be  secured. 

The  patient  must  be  carefully  imbued  with  the  fact  that 
his  symptoms  do  not  depend  upon  organic  mischief;  that  to  a 
large  extent  his  convalescence  depends  upon  his  doing  exactly 
what  he  is  advised  to  do ;  and  that  if  he  does  this,  and  avoids 
all  things  likely  to  weaken  and  depress  him  further,  he  will 
probably  recover  his  health  in  time. 

The  building  up  of  nervous  force  is  at  all  times  a  difficult 
task,  as  the  centres  discharge  their  energy  under  the  most 
trifling  provocations,  which  leads  to  relapses,  and  of  this  the 
patient  should  be  warned,  so  that  he  may  not  be  too  downcast 
when  they  do  occur.  He  must  be  inspired  with  hope  and  con- 
fidence, and  have  his  life  arranged  upon  strictly  physiological 
grounds,  in  which  food,  stimulant,  and  mental  and  physical 
work  should  be  well  balanced,  and  bear  an  intimate  relation 
the  one  to  the  other.  If  the  symptoms  are  very  urgent,  he 
must  be  advised  to  give  up  regular  employment,  and  to  rest 
the  jaded  brain  by  calling  into  use  new  psychical  centres, 
through  new  channels  of  thought.  What  direction  or  form 


Insomnia  and  its   Therapeutics.  91 

this  new  work  should  take  must  be  determined  by  the  patient 
himself,  sua  cuique  voluptas;  the  physician  can  only  indicate 
its  necessity.  Carlyle  wrote  these  words :  "  The  modern  ma- 
jesty consists  in  work.  What  a  man  can  do  is  his  greatest 
ornament,  and  he  always  consults  his  dignity  by  doing  it." 
To  ask  a  patient  to  give  up  his  usual  occupation  without  ex- 
plaining the  need  for  a  new  one,  is  to  intensify  his  sufferings; 
for  mental  work  of  a  new  and  pleasurable  kind  not  only  tends 
to  deplete  the  over-wrought  centres,  but  by  its  distraction  to 
dispel  gloom  and  depression,  and  to  render  him  less  conscious 
of  his  woes,  which  to  him  is  of  no  small  import.  Happier 
mentally,  the  control  of  temper  will  become  easier,  he  will  be 
able  to  dominate  himself,  and  will  lose  much  of  the  mental  in- 
decision which  is  so  distressing  to  those  to  whom  it  was  un- 
known in  former  years.  Vacillation  will  be  replaced  \)y  de- 
termination of  purpose,  which  will  increase  month  by  month, 
if  not  day  by  day,  and  exemplify  the  scriptural  truth,  "  Unto 
him  that  hath  shall  be  given." 

The  question  of  exercise  is  important.  It  must  at  all 
times  be  kept  strictly  within  the  limits  of  fatigue;  for  fatigue 
invariably  intensifies  the  symptoms,  whatever  that  limit  may 
be.  The  amount  to  be  taken  must  be  determined  in  each 
separate  case,  and  it  must  not  be  forgotten  that  it  has  a  high 
therapeutic  value,  as  a  derivative  in  local  congestions,  such 
as  occur  in  mental  overwork ;  and  in  hyper-excitability  of  the 
sexual  organs  it  can  scarcely  be  esteemed  too  highly.  Within 
due  limits  it  tends,  in  all  cases,  to  increase  the  bodily  vigor 
by  exciting  the  appetite  and  by  quickening  and  perfecting  the 
digestive  processes.  Walking,  riding,  rowing,  and  gymnastic 
exercises  are  all  useful,  and  each  has  its  special  indication. 
In  genital  and  pelvic  derangements,  rowing  and  the  use  of 
light  dumb-bells  or  clubs  are  to  be  preferred  to  walking,  which 
attracts  blood  to  the  lower  extremities.  On  the  other  hand, 
the  exercise  of  the  muscles  of  the  arms,  back,  and  chest  di- 
verts the  blood  from  the  pelvis.  Riding  is  specially  useful  to 
those  who  have  led  sedentary  lives,  and  whose  biliary  and  di- 
gestive organs  are  impaired ;  the  invigoration  in  many  cases 
being  rapid  and  appreciable.  For  those  who  have  sufficient 
strength,  a  walking  tour,  or  shooting,  or  fishing  often  proves 
beneficial.  Exercise  properly  regulated  is,  for  the  reasons 
already  mentioned,  an  exceedingly  valuable  means  of  promot- 
ing sleep,  and  particularly  if  it  is  taken  in  the  open  air. 


92  Insomnia  and  its  Therapeutics. 

The  food  will  demand  careful  attention,  for  the  aim  must 
be  to  increase  as  speedily  as  possible  the  quantity  and  the 
quality  of  the  blood,  as  well  as  the  store  of  fat,  so  essential 
for  the  nourishment  of  the  nervous  system.  It  is  consequently 
necessary  to  feed  up  to  the  extreme  limit  of  the  digestive 
powers.  Unfortunately,  these  are  in  most  cases  impaired, 
and  in  almost  all  they  are  easily  overtaxed  and  deranged. 
This  latter  must  be  carefully  avoided,  for  much  time  may  be 
consumed  in  restoring1  the  impaired  function. 

When  the  digestive  powers  will  bear  it,  two  substantial 
meals  should  be  taken  daily;  the  first  about  one  o'clock,  the 
second  about  seven  P.M.,  each  consisting  of  clear  soup,  meat 
(such  as  beef,  mutton,  poultry,  venison,  or  game),  and  milk 
puddings  or  stewed  fruit  with  cream;  varied  every  alternate 
day  by  fish  being  substituted  for  soup.  The  fish  should  be, 
preferably,  raw  oysters,  whiting,  sole,  haddock,  turbot,  or 
brill.  Green  vegetables  boiled  in  a  plentiful  supply  of  water 
should  be  eaten  freely,  also  salads  and  tomatoes;  potatoes 
more  sparingly.  Besides  these,  there  should  be  at  least  two 
other  meals;  a  substantial  breakfast  of  Scotch  porridge  and. 
cream,  followed  by  chocolate  or  cocoa  (made  from  the  nibs), 
with  toasted  bread  (preferably  brown)  and  butter,  fat  bacon, 
and  lightly  boiled  eggs.  In  the  afternoon,  in  lieu  of  tea,  a 
tumblerful  of  peptonized  milk  or  koumiss.  Each  individual 
diathesis  must  be  considered,  and  the  diet  varied  to  suit  each 
separate  case.  Occasionally,  much  good  accrues  from  the 
use  of  peptic  and  pancreatic  liquors,  and  malt  extracts  taken 
at  suitable  times;  or  lactopeptine  and  ingluvin  may  be  tried. 

When  the  digestion  is  weak,  it  may  be  desirable  to  limit 
the  amount  of  butcher  meat.  In  constipation,  it  may  be  nec- 
essary to  avoid  milk  and  eggs.  If  there  is  great  prostration, 
small  meals  every  two  or  three  hours  must  be  resorted  to, 
beginning  in  the  morning  at  seven  with  boiled  milk,  sugar, 
and  a  spoonful  of  rum  or  brandy,  following  it  up  with  the 
most  easily  assimilated  food  possible,  such  as  raw-meat  juice, 
clear  soups,  custards,  peptonized  food,  koumiss,  or  Loeflund's 
Cremor  hordeatus.  In  these  cases  it  is  necessary  to  give  sup- 
port when  they  awaken  during  the  night. 

Stimulant. — While  many  cases  are  best  treated  without 
stimulant,  others  derive  benefit  from  its  moderate  use.  The 
quantity  prescribed  must  be  limited  to  that  which  increases 


Insomnia  and  its   Therapeutics.  93 

the  power  and  tone  of  the  heart  and  blood-vessels,  augments 
the  appetite,  promotes  digestion  and  nutrition,  and  is  not  fol- 
lowed by  marked  depression.  This  quantity  varies  greatly  in 
different  persons,  and  can  only  be  estimated  in  each  individual 
case  by  careful  observation  and  consideration.  Its  limit  will 
probably  be  found,  in  all,  not  to  exceed,  of  whiskey  or  brandy, 
one  or  two  wineglassfuls;  of  port  or  sherry,  two  wineglass- 
fuls;  of  burgundy,  claret,  hock,  or  champagne,  one  pint;  or  of 
Burton  ale  or  porter  one  quart,  in  twenty-four  hours. 

In  many  cases  a  much  less  quantitj"  will  suffice,  for  if  the 
physiological  amount  is  exceeded  it  retards  recovery.  In 
some,  when  there  is  a  congested  condition  of  the  brain,  its  use 
must  be  avoided.  The  choice  of  the  stimulant  may  be  left  to 
some  extent  to  the  patient,  but  it  is  well  to  recollect  that 
whiskey  and  brandy  retard  digestion  less  than  sherry  and 
port  (Sir  William  Roberts),  and  that  they  owe  their  efficacy 
to  the  alcohol  they  contain;  while  wine  contains  ether;  and 
beer,  hops.  All  stimulants  should  be  ordered  to  be  taken  with 
meals,  and  when  they  are  required  as  a  night-cap  at  bedtime 
for  the  purpose  of  promoting  sleep,  it  is  always  advisable  to 
associate  them  with  a  light  repast.  For  example,  a  cupful  of 
arrowroot  with  some  brandy  or  whiskey  with  sugar ;  a  whipped 
egg  with  brandy  and  sugar,  and  this  is  improved  by  a  tea- 
spoonful  of  chloric  ether;  white-wine  whey  and  a  biscuit; 
caudle,  made  of  gruel  and  wine  with  nutmeg  and  sugar;  mulled 
port,  claret,  or  porter;  warm  spiced  ale;  brandy  or  whiskey 
todd3r,  with  or  without  nutmeg,  taken  with  a  biscuit,  are  each 
and  all  suitable  in  selected  cases. 

When  it  is  desirable  to  avoid  ordering  stimulant  in  such 
convenient  forms,  the  mistura  spiritus  vini  gallici  of  the  Phar- 
macopoeia flavored  with  chloric  ether  can  be  obtained  from 
the  chemist. 

Prescribing  stimulant  is  always  a  matter  of  grave  responsi- 
bility in  these  cases.  Flushing,  as  it  speedily  does,  the  brain 
with  blood,  and  lessening  almost  instantaneously  depression 
and  gloom,  the  temptation  to  resort  to  its  frequent  use  be- 
comes great.  This  is  particularly  true  in  cases  where  the 
centres  of  volition  are  enfeebled;  and  in  the  cases  of  neurotics, 
who  acquire  habits  with  great  facility,  it  is  far  from  being  de- 
void of  risk.  A  medical  prescription  to  take  a  certain  quantity 
of  alcohol  at  stated  times  has  often  been  exceeded  during  an 


94  Insomnia  and  its   Therapeutics. 

illness,  and  continued  after  recovery,  until  it  has  resulted  in 
chronic  alcoholism;  medicines  and  regimen  have  been  dis- 
pensed with,  but  the  leave  to  take  stimulant  retained,  leading 
to  moral,  mental,  and  physical  disaster.  Such  an  event  must 
be  guarded  against  with  the  utmost  care. 

Many  neurasthenics  who  waken  in  the  early  morning-  and 
lie  or  wander  about  miserable  and  depressed,  are  soothed, 
comforted,  and  enabled  to  sleep  by  taking  a  cupful  of  warm 
beef  tea,  or  milk  with  a  spoonful  of  brandy  or  whiskey;  just 
as  many  a  worn-out  phthisical  patient  is  strengthened  on 
awaking  by  a  cupful  of  warm  milk  with  some  sugar  and  a 
spoonful  of  rum. 

The  clothing  sMould  be  light  and  warm;  light,  because 
these  patients  fret  under  the  burden  of  heavy  clothes;  and 
warm,  for  the  reason  that  they  are  susceptible  to  the  influence 
of  cold  and  draughts. 

Baths  judiciously  employed  are  often  of  great  service.  The 
morning  bath  should  be  tepid,  or  if  cold  the  patient  should 
stand  with  his  feet  in  hot  water  and  carry  out  his  ablutions 
quickly.  The  Turkish  and  sitz  baths  may  be  employed  in  the 
slighter  cases;  also  the  needle  or  shower  baths.  The  wet 
pack  at  night  is  a  powerful  hypnotic,  and  it  is  generally  well 
borne.  Sea-bathing  is  particularly  invigorating,  especialhr 
when  the  patient  can  swim.  Sea-air,  abundant  as  it  is  in 
ozone,  has  a  highly  tonic  effect  upon  the  system ;  to  dwellers 
in  offices  deficient  in  oxygen,  or  in  other  unhealthy  surround- 
ings, it  is  invaluable.  Unfortunately,  however,  as  it  was 
pointed  out  in  the  first  chapter,  neurotics  often  fail  to  sleep 
well  at  the  seaside,  and  when  this  is  the  case  sea-bathing  is 
of  course  contra-indicated.  When  it  does  not  per  se  cause 
sleeplessness  it  is  an  aid  not  to  be  neglected,  the  selection  of 
the  watering-place  depending  a  good  deal  upon  the  strength 
and  temperament  of  the  patient.  In  this  country  there  is  no 
lack  of  seaside  health  resorts  to  meet  almost  every  descrip- 
tion of  case ;  while  abroad  their  name  is  legion. 

Dry  and  bracing  climates  suit  neurasthenics  best,  the  ex- 
ception being  that  just  referred  to,  where  there  is  a  tendency 
to  excitement,  in  which  case  a  sedative  climate  must  be  recom- 
mended. A  prolonged  stay  in  a  hilly  country  is  invariably 
productive  of  good  results,  and  when  disappointment  has 
been  experienced  it  has  probably  been  due  to  the  fact  of  the 


Insomnia  and  its   Therapeutics.  95 

residence  not  being  sufficiently  prolonged.  In  this  country 
we  have  many  excellent  climates.  Among-  them,  there  are 
the  Sussex  Downs,  Malvern,  Leamington,  Falmouth,  and  the 
Yorkshire  dales.  The  highlands  of  Scotland  offer  many  ad- 
vantages. Mountaig  air  has  been  compared  to  drinking 
champagne  without  the  bad  effects.  Abroad,  there  are  many 
desirable  resorts.  The  writer  has  seen  most  good  accrue 
from  residences  in  Switzerland,  Egypt,  and  the  Cape.  In 
selecting  a  residence  the  capabilities  of  the  place  must  be  con- 
sidered— its  amusements,  social  life,  historical,  geological,  or 
botanical  attractions — with  reference  to  the  tastes  of  the 
patient,  for  unless  reasonable  entertainment  can  be  had,  he 
grows  weary,  restless,  and  irritable,  and  fails  to  derive  benefit 
from  the  change.  He  must  have  mental  occupation,  and  the 
varieties  to  be  found  in  a  neighborhood  are  important  factors 
with  regard  to  its  selection. 

It  is  very  desirable  that  the  patient  should  be  able  to  live 
in  the  open  air,  and  that  he  should  have  plenty  of  sunshine. 
Ladies  who  have  broken  down  under  the  strain  of  nursing  and 
anxiety  often  recruit  during  long  sea-voyages,  where  they  can 
enjoy  quiet  rest  away  from  all  depressing  cares.  These  pa- 
tients, however,  must  not  undertake  such  expeditions  if  they 
are  very  debilitated,  as  stormy  weather  and  unsuitable  food 
may  aggravate  their  state. 

Business  men  likewise  derive  benefit  from  long  cruises,  as, 
out  of  reach  of  telegrams  and  letters,  freed  from  the  knowl- 
edge— ever  recurring — of  stock-exchange  fluctuations  and 
market  prices,  their  nervous  systems  obtain  the  rest  they  so 
urgently  require.  In  a  certain  number  of  cases  in  which  ex- 
treme emaciation  and  prostration  are  the  prominent  symp- 
toms, chiefly  met  with  among  neurotic  women — occasionally 
the  subjects  of  uterine  ailments — the  treatment  suggested  by 
Dr.  Weir-Mitchell  appears  to  be  exceptionally  valuable.  It 
consists  in  removing  the  patient  from  her  surroundings  and 
S3rmpathizing  friends,  in  isolating  her  for  several  weeks,  keep- 
ing her  in  bed,  and  filling  up  the  day  with  massage,  electriza- 
tion, and  large  feeding.  Further  details  upon  this  question 
must  be  obtained  from  the  many  special  works  on  the  subject. 

Electricity  is  an  admirable  remedy  in  many  cases  of  neuras- 
thenia, whether  it  be  used  in  the  form  of  central  galvaniza- 
tion or  general  faradization.  Its  effects  are  felt  by  the  whole 


g6  Insomnia  and  its  Therapeutics. 

economy;  the  mental  depression  becomes  lessened  and  is  re- 
placed by  hopefulness;  the  aspect  of  the  patient  becomes 
brighter,  and  the  carriage  and  bearing1  firmer  and  more  elas- 
tic; the  walking1  powers  improve,  the  limbs  being-  more  under 
control;  pains  in  the  spine  and  muscles  grow  less  and  vanish; 
the  appetite  is  increased,  and  dyspeptic  derangements  disap- 
pear ;  the  bowels  begin  to  act  naturally ;  improved  nutrition 
manifests  itself  in  increased  body  weight;  and  in  the  majority 
of  cases  insomnia  either  disappears  or  is  greatly  amended. 
The  writer  in  advising  galvanization  directs  that  on  alternate 
days  very  weak  currents  should  be  passed  from  the  positive 
pole  placed  upon  the  forehead  to  the  negative  on  the  upper 
part  of  the  spine;  then  from  the  positive  pole  pressed  close 
into  the  angle  of  the  jaw  to  the  negative  on  the  seventh  cervi- 
cal vertebra ;  afterward,  stronger  currents,  from  the  positive 
pole  situated  over  the  cervical  vertebrae  to  the  negative  in  the 
epigastrium ;  and  lastly,  to  the  negative  placed  in  a  foot-bath. 
He  relies  upon  weak  and  prolonged  currents,  lasting  from 
twenty  to  sixty  minutes,  rather  than  upon  strong  currents ; 
and  in  all  cases  he  insists  on  the  necessity  of  avoiding  any  in- 
terruption of  the  current.  Every  now  and  again  this  useful 
means  of  treatment  fails  to  improve  sleep,  and  appears  to 
aggravate  the  other  symptoms;  it  is  therefore  necessary  to 
watch  its  effects.  Improvement  of  sleep  is  always  the  pre- 
cursor of  other  benefits. 

The  question  of  medication  naturally  arises  here.  The 
remedies  must  be  selected  from  among  the  nervine  and  haema- 
tic tonics,  but  their  administration  should  in  every  case  be 
preceded  by  the  correction  of  any  stomachic  and  biliary  de- 
rangements. It  must  be  admitted  that  while  some  patients 
derive  considerable  benefit  from  tonics,  there  is  a  minority 
who  are  not  improved  by  their  use.  When  there  is  any  cere- 
bral congestion  they  are  best  .avoided  altogether.  Among 
the  multitude  of  tonics  the  following  have  been  found  reliable 
in  many  cases,  particularly  in  those  with  relaxed  arterial  ten- 
sion: 

^  Phosphid.  zinc.,  ....    gr.  ^  vel  gr.  ss. 

Ferri.  redact., gr.  iij. 

Ext.  calumb., q.  s. 

Ft.  pil.  i.     Sig.  Take  one  after  meals  thrice  daily. 


Insomnia  and  its  Therapeutics.  97 

^   Ferri  arseniat.,    ....     gr.  -fa  vel  gr.  ss. 

Mastich.,      .  • gr.  ij. 

Ft.  pil.  i.    Sig.  Take  one  after  meals  thrice  daily. 

Or, 

$  Sulph.  quinin.,      .        .        ,        *        ...    gr.  i. 

Ext.  nucis  vom.,  .        .        .        ,        ,        .    gr.  ss. 

Pulv.  digital.,       .        .        .  •",        .    gr.  i. 

Ext.  gentian.,       .        .        .        .        .        .     q.  s. 

Ft.  pil.  i.     Sig.  Take  one  between  meals  thrice  daily. 

Ergotin  may  be  added  to  either  of  these.  In  suitable  cases 
cod-liver  oil  with  sulphuric  ether  may  be  advantageously  rec- 
ommended. 

The  bowels  are  not  infrequently  constipated.  This  must 
be  met  loy  appropriate  diet,  by  electricity,  and  abdominal  com- 
presses worn  during  the  night.  If  medicines  are  required, 
warm  and  mild  laxatives  should  be  preferred,  for  all  purga- 
tion increases  nervous  exhaustion.  The  following  have  been 
found  useful: 

B  Aloin., gr.  i. 

Ext.  bellad., gr.  $. 

Ext.  hyoscy., gr.  iij. 

Ft.  pil.  i.    Sig.  Take  at  bedtime. 

Or, 

]J  Pil.  coloc.  co.  vel  pil.  rhei.  co., .        .        .    gr.  iiss. 

Ext.  lupul., gr.  ij. 

Ft.  pil.  i.     Sig.  Take  one  at  bedtime. 

In  many  cases,  the  treatment  of  neurasthenia  upon  the 
foregoing  lines  is  all  that  is  required  for  the  accompanying- 
insomnia,  but  in  others  this  symptom  requires  special  atten- 
tion. It  is  important  to  unravel  the  cause  upon  which  it  de- 
pends in  the  particular  case ;  for  it  follows  from  the  causation 
of  neurasthenia  being  most  diverse,  that  the  insomnia  must 
depend  upon  equally  varied  conditions. 

The  sleeplessness  which  occurs  in  neurasthenic  conditions 
induced  by  excessive  brain  work,  shock,  or  depressing  mental 
emotions,  by  the  indiscreet  use  of  tea  and  tobacco,  or  by  ma- 
laria, syphilis,  rheumatism,  or  gout,  is  discussed  under  these 
various  heads. 


98  Insomnia  and  its  Therapeutics. 

When  cerebral  anaemia  is  present,  it  is  important  to  decide 
the  state  of  the  blood-tension,  for  although  it  is  usually  "  low  " 
in  anaemic  conditions,  it  is  not  invariably  so,  and  sometimes 
treatment  directed  to  this  point  is  attended  by  eminently  sat- 
isfactory results.  The  estimation  of  blood-pressure  is  always 
a  valuable  guide  in  deciding  the  treatment  of  insomnia,  not 
specially  in  neurasthenia,  but  in  all  cases.  If  the  tension  be 
"  high,"  a  few  minute  doses  of  calomel  at  night,  with  alkalies 
during  the  day,  are  indicated. 

fy  Subchlor.  hydrarg.,    .        .        .    gr.  ss.  vel  gr.  1. 

Ext.  hyoscy.,       ....    gr.  ij.  vel  gr.  iv. 
Ft.  pil.  i.     Sig.  Take  one  every  night  for  four  nights. 

]£  Bicarb,  potass.,     .  ....    3  iij. 

Tinct.  aconit.,  B.  P., TTJ,  xx. 

Aquam, ad  §  vi. 

M.  Sig.  Take  a  tablespoonful,  in  water,  before  meals 
thrice  daily. 

Instead  of  this  mixture,  two  grains  of  sodium  nitrite  may  be 
given  thrice  daily  between  meals.  Dry  cupping  in  selected 
cases  is  occasionally  serviceable. 

When  the  insomnia  is  due  to  such  enervating  causes  as  ex- 
cessive discharges,  excesses,  prolonged  bodily  fatigue  (sleep- 
lessness dependent  on  physical  over-fatigue  is  best  relieved  by 
the  wet  pack,  or  a  warm  bath,  with  some  liquid  nourishment. 
A  suitable  repast  is  a  cupful  of  meat  juice,  containing  a  few 
spoonfuls  of  wine  or  brandy,  with  a  biscuit.  The  addition  of 
3  ss.  of  tincture  of  arnica  is  an  improvement.  A  heavy  meal 
eaten  when  one  is  over-fatigued  will  not  digest,  and  the  de- 
rangement it  initiates  increases  the  sleep  disturbance.  In 
certain  country  districts  of  England  there  is  a  firmly-rooted 
belief  that  primrose  [primula]  wine  relieves  the  feeling  of  ex- 
haustion, and  promotes  sleep.  The  writer  has  never  been  able 
to  assure  himself  whether  its  good  effects  are  attributable  to 
the  brandy  it  contains,  the  mental  impression  its  administra- 
tion insures,  or  to  the  constituents  of  the  flowers.  It  is  be- 
yond doubt  that  it  is  occasionally  efficacious.  It  is  further 
worth  noting  that  the  belief  has  lived  through  centuries,  and 
that  even  now  many  persons  grow  primroses  specially  for  the 
purpose  of  manufacturing  the  wino),  or  over-excitement,  mas- 


Insomnia  and  its  Therapeutics.  99 

sage  before  bedtime  tends  to  promote  sleep ;  speedily  in  a  few, 
more  tardily  in  the  majority  of  instances.  It  practically  con- 
sists of  cutaneous  rubbings,  muscle  kneadings,  and  joint  move- 
ments. It  increases  the  activity  of  the  circulation  and  lymph- 
flow  through  the  skin  and  muscles,  and  stimulates  all  the 
processes  of  the  economy.  It  likewise  raises  the  temperature 
of  the  cutaneous  surface,  and  attracts  to  the  integument  and 
muscles  an  increased  quantity  of  blood,  depleting  to  a  corre- 
sponding extent  the  blood-vessels  of  the  brain — a  condition 
favorable  to  sleep. 

There  are  many  remedies  that  in  individual  cases  offer  ad- 
vantages, e.g.,  chloric  ether  is  an  excellent  stimulant,  which 
conduces  to  sleep  by  allaying  excitement  in  the  nervous  cen- 
tres, either  given  alone,  or  as  an  adjunct,  to  increase  the  dif- 
fusibility  of  more  potent  remedies.  Along  with  sumbul  it  acts 
as  a  cerebro-spinal  sedative,  calming  excitement,  subduing 
restlessness,  and  thus  bringing*  about  conditions  essential  to 
sleep.  Hop,  containing  the  active  principle  lupulin,  has  long 
been  credited  with  hypnotic  properties,  and  it  is  partly  owing 
to  this  that  malt  liquors  act  as  hypnotics;  it  is  a  stomachic 
tonic  and  cerebral  sedative  which  allays  excitement  and  pro- 
motes sleep.  A  very  old  and  favorite  prescription  combining 
these  three  remedies  is: 

IJ  Spt.  chloroform., '    .     f  ss. 

Tinct.  sumbul., §  ss. 

Tinct.  lupul., §  i. 

M.  Sig.  Take  two  teaspoonfuls  in  water  every  hour  or 
two  until  sleep  is  procured. 

A  very  similar  and  valuable  remedy  is : 

B  Tinct.  digital.,       .        .        ,        ...        .    TTI  xx. 

Tinct.  sumbul., 3  i. 

Tinct.  lupul., 3  ij. 

Aquam, ad  |  ij. 

M.  Sig.  Take  one-half  at  bedtime,  in  water,  and  repeat 
in  two  hours  if  required. 

Lupulin  may  be  given  in  pill  an  hour  before  bedtime,  in 
doses  of  two  to  five  grains,  and  it  may  be  repeated  if  neces- 
sary. The  bromides  and  bromidia  are  frequently  of  con- 
siderable service  when  there  is  not  pronounced  anaemia,  but 


ioo  Insomnia  and  its  Therapeutics. 

their  use  should  not  be  persevered  in  for  more  than  six  nights. 
Monobromide  of  camphor,  cannabis  indica,  tannate  of  canna- 
bin,  hyoscyamus,  are  each  and  all  useful  in  various  cases. 

The  writer  has  obtained  very  satisfactory  results  from  the 
new  hypnotic  sulphonal,  in  doses  varying-  from  gr.  xx.  to  gr. 
xl.  In  obstinate  cases  chloral  hydrate  may  be  given,  but 
never  for  more  than  a  few  nights.  Morphine  may  also  be  re- 
quired occasionally,  but  its  use  should  likewise  be  restricted. 
It  is  best  given  hypodermically  with  atropine,  e.g.  from  -^  to 
\  of  a  grain  of  morphine,  with  -j-J^  of  a  grain  of  atropine ;  or  it 
may  be  combined  with  bromide  and  chloral  hydrate. 

$  Liq.  morphin.  acet.,       .        .        .     iri  xl.  vel  3  i. 
Hydrat.  chloral,    .        .        .        .   gr.  xl.  vel  3  i. 

Brom.  sodii, 3ij. 

Syr.  tolu., 3  iv. 

Aquam,  _*        .        .        .  ad  §  iv. 

M.  Sig.  Take  one-fourth  part  in  water,  before  bedtime, 
and  repeat  in  two  hours  if  required. 


CHAPTER  V. 

INSOMNIA  DEPENDING    UPON  AFFECTIONS  OF  THE 
NERVOUS  SYSTEM—  Continued. 

HYSTERIA. 

THE  predisposing-  cause  of  this  affection  is  a  nervous  sys- 
tem defective  in  stamina,  and  consequently  unduly  impres- 
sionable. Such  nervous  textures  seem  liable  to  have  their 
functions  perverted  in  a  curious  way  by  various  exciting- 
causes.  These  lead  to  a  perversion  rather  than  to  a  modifica- 
tion of  function.  The  victims  of  this  disease  have  a  tendency 
to  neurotic  maladies,  and  their  emotional  centres  dominate 
their  volitional.  It  affects  females  above  fifteen  years  of  age, 
and  most  frequently  at  the  epochs  of  puberty  and  the  meno- 
pause. It  is,  however,  not  peculiar  to  the  sex,  as  it  affects 
males,  though  less  frequently;  being  excited  and  developed 
by  all  conditions  which  exhaust  the  reserve  store  of  nervous 
energy.  It  may  be  caused  by  violent  and  depressing  emo- 
tions, disappointments,  over-excitement,  and  prolonged  anx- 
iety; by  lives  so  devoid  of  healthy  mental  and  physical  occu- 
pation as  to  engender  introspection  and  self-consciousness;  by 
all  diseases  and  excesses  which  enfeeble  the  body;  and  reflexly, 
by  uterine  and  ovarian  derangements,  which  act  prejudicially 
on  the  nervous  system. 

All  such  causes  are  unfavorable  for  sleep.  It  is  therefore 
not  surprising  that  this  affection,  in  its  many  phases,  is  the 
source  of  disturbed  sleep,  and,  at  times,  of  persistent  insomnia. 
In  investigating  this  point,  it  is  necessary  to  be  careful  not  to 
allow  the  patient  to  think  that  sleep  is  an  object  of  special 
interest,  for  so  desirous  are  many  of  them  to  excite  attention 
and  sympathy,  that  they  may  develop  sleeplessness  as  a 
marked  feature. 

The  symptoms  of  hysteria  are  of  the  most  varied  nature; 
we  can  only  indicate  a  few  very  briefly.  As  in  the  allied  con- 
ditions of  epilepsy  and  hypochondriasis,  there  is  a  paroxysmal 


IO2  Insomnia  and  its  Therapeutics. 

element  in  almost  every  case.  There  is  a  marked  tendency  to 
emotional  excitement;  to  laugh,  cry,  and  scream  alternately, 
on  the  least  provocation.  The  temper  is  .perverse  and  uncer- 
tain, and  the  morbid  craving1  for  sympathy  referred  to  leads, 
in  some  instances,  to  deceit,  and  even  to  disgusting  practices. 
Sufferers  from  hysteria  are  prone  to  disturbance  of  the  special 
senses,  which  renders  them  peculiarly  sensitive  to  sounds  and 
other  external  stimulations — one  of  the  fruitful  sources  of  in- 
somnia; also  to  general  hyperaesthesia,  though  at  times  the 
reverse  condition  of  anaesthesia  is  met  with;  and  even  paraly- 
sis, the  diagnosis  of  which  is  by  no  means  easy.  They  may 
experience  neuralgic  pains  in  various  parts  of  the  body,  prom- 
inent among  which  is  spinal  irritation,  mastodynia,  etc.  They 
also  suffer  from  convulsive  attacks  (hysterical  fits),  which 
differ  from  epileptic  seizures  in  that  they  never  come  on  dur- 
ing sleep,  and  are  never  attended  by  injury  at  the  onset  of 
the  fit,  or  by  biting  of  the  tongue,  etc. ;  though  they  may  re- 
semble epilepsy  in  being  frequently  followed  by  deep  sleep. 
Between  their  paroxysmal  attacks,  hysterical  patients  fre- 
quently suffer  from  functional  perturbations,  respiratory  and 
gastro-intestinal  derangements,  ef  which  latter  flatulence  is 
a  prominent  symptom;  and  sometimes  they  pass  enormous 
quantities  of  pale  urine  of  low  specific  gravity,  the  result  of 
high  blood-tension.  This  condition  of  the  blood-vessels  ac- 
counts in  some  degree  for  the  sleeplessness  with  which  they 
are  afflicted. 

Treatment. — In  no  disease  is  it  more  essential  to  cultivate 
a  good  habit  of  sleep.  It  is  especially  necessary  that  the  vic- 
tims of  hysteria  should  not  spend  too  many  hours  in  bed,  and 
that  they  should  rise  immediately  after  awaking,  as  indolent 
dreaming  in  the  morning  tends  to  further  enervation,  and  to 
aggravate  the  whole  condition.  Every  endeavor  must  be 
made  to  obtain  the  confidence  of  the  patient,  not  by  sympa- 
thizing with  her  so  much  as  by  dominating  her  by  judicious 
yet  kindly  counsel. 

It  is  necessary  to  inspire  her  with  the  conviction  that  she 
can  implicitly  trust  her  adviser  to  make  her  well;  to  do  this 
the  proverbial  "  hand  of  iron  in  a  glove  of  velvet "  is  required. 
The  diet  should  be  plain  and  non-stimulating,  and  taken  at 
regular  hours.  All  alcoholic  drinks  are,  except  in  very  ex- 
ceptional cases,  best  avoided.  Baths  are  invaluable:  the 


Insomnia  and  its  Therapeutics.  103 

morning1  tepid  bath,  followed  by  brisk  rubbing;  the  spinal 
douche,  cold  water  poured  down  the  spine  while  sitting1  in  hot 
water;  and,  in  suitable  cases,  the  sitz  bath.  Exercise  in  the 
open  air,  particularly  in  the  morning,  short  of  fatigue,  is  of 
the  first  importance,  and  must  be  insisted  on.  The  variety 
must  depend  largely  upon  the  strength  of  the  patient  and 
the  depth  of  the  purse,  and  to  some  extent  upon  the  tastes  of 
the  sufferer.  Change  of  air  and  scene  may  be  called  for,  as  a 
means  of  securing  healthy  mental  occupation.  Every  exer- 
tion must  be  made  to  engender  self-control.  Uterine,  ovarian, 
and  other  derangements  demand  attention.  Tonic  remedies 
are  usually  prescribed.  Probably  the  best  are  phosphorus, 
arsenic,  quinine,  strychnine,  and  the  valerianates  of  zinc  and 
ammonium.  Electricity  exceeds  them  all  in  value,  while  it  is 
a  useful  aid  to  sleep.  General  faradization  is  the  most  effica- 
cious. In  many  cases  it  is  necessary  to  resort  to  special 
means  to  obtain  sleep  for  a  few  nights.  The  calming  influ- 
ences of  a  hot  foot  bath,  and  douching  the  head  with  tepid 
water,  deserve  a  trial.  The  late  Dr.  Graves,  of  Dublin,  strongly 
recommended  the  use  of  musk  in  these  patients.  He  quotes 
one  case  in  which  "  all  kinds  of  narcotics  had  been  tried  un- 
successfully, and  opium,  in  all  its  forms,  had  failed  in  procur- 
ing sleep.  I  advised  the  use  of  musk  in  doses  of  a  grain  every 
second  hour,  and  this  means  proved  eminently  successful." 
Musk,  however,  on  account  of  its  great  cost,  is  now  seldom 
employed.  The  ammoniated  tincture  of  valerian  with  cam- 
phor is  an  excellent  remedy,  given  once  or  twice  before  bed- 
time. 

B  Tinct.  valerian,  ammon.,        .        .        .        .     3  vi. 
Spt.  camphor.,         .        .        .        .        .        .     3  i. 

Aq.  chlorof., §  vi. 

Sig.  Take  two  tablespoonfuls  every  two  hours  until  sleep 
is  induced. 

A  mixture  of  hop,  sumbul,  and  chloric  ether  also  answers 
well,  and  it  may  be  repeated  (p.  597). 

Paraldehyde,  in  doses  ranging  from  iU  xxx.  to  Til  xlv.  in 
syrup  and  water  at  bedtime  is  useful,  all  the  more  that  its 
taste  is  unpleasant.  Monobromide  of  camphor  is  efficacious, 
and  amylene  hydrate  has  been  recommended. 

The  bromides,  chloral  hydrate,  and  even  morphine  by  hy- 


104  Insomnia  and  its   Therapeutics. 

podermic  injection  may  in  some  instances  be  called  for,  as  it 
was  in  a  recent  case,  which  was  complicated  by  anuria  of  sev- 
eral weeks'  duration.  In  the  last  two  cases  under  treatment, 
sulphonal  acted  most  admirably,  improvement  quickly  follow- 
ing- its  use. 

HYPOCHONDRIASIS. 

Hypochondriasis  is  frequently  accompanied  by  sleepless- 
ness more  or  less  pronounced;  although  it  may  not  be  ur- 
gently complained  of,  being-  overshadowed  by  the  greater 
misery  of  morbid  depression  and  painful  sensations.  In  the 
cases  in  which  want  of  sleep  is  a  prominent  symptom,  its  ex- 
tent majr  be  greatly  exaggerated,  for  when  the  patient's  at- 
tention is  attracted  to  it  he  is  liable  to  misinterpret  both  the 
quantity  and  quality  of  his  sleep.  In  all  such  patients  it  is 
necessary  to  inquire  carefully  into  the  habit  of  sleep,  that  any 
disturbance  may  be  remedied,  aggravating  as  it  does  all  the 
other  symptoms;  while  sound  sleep  sufficiently  prolonged 
tends  to  ameliorate  them.  Hypochondriasis  is  probably  due, 
primarily,  to  functional  disorder  of  the  cerebral  centres,  which 
causes  them  to  originate  sensations,  as  of  visceral  or  periph- 
eral disturbance,  which  do  not  exist;  and  to  be  abnormally 
sensitive  to  impressions,  not  usually  perceived,  arising  in  dis- 
tant parts.  Cells  so  perverted  in  function,  and  so  preter- 
naturally  perceptive,  are  productive  of  a  distorted  conscious- 
ness when  awake,  and  are  susceptible  to  the  most  trivial 
impressions  arising  during  sleep;  hence  the  disturbance  of 
sleep. 

In  many  cases  the  symptoms  are  limited  to  one  system, 
and  upon  these  the  thoughts  are  concentrated  until  the  sensa- 
tions gradually  deepen  into  pain,  it  may  be  of  an  agonizing 
kind,  and  although  of  central  origin,  most  real  to  the  sufferer. 
Frequently  all  the  symptoms  are  referred  to  the  sexual  organs, 
the  patient  believing  himself  to  be  impotent  or  the  victim  of 
venereal  disease;  and  in  the  female,  they  may  be  associated 
with  severe  pain  in  the  vulva. 

The  morbid  introspection  and  mental  depression,  which 
are  out  of  all  proportion  to  the  ailments  complained  of,  lead 
secondarily  to  enfeeblement  of  the  mind,  and  enervation  of 
the  circulatory  and  respiratory  systems  and  of  the  digestive 
and  hepatic  functions.  Hence  arise  such  symptoms  as  flush- 


Insomnia  and  its   Therapeutics.  105 


ings,  vertigo,  tinnitus,  confusion,  and  weariness  of  thought, 
palpitation,  arterial  pulsations,  sighing,  sense  of  sinking  at 
the  epigastrium,  disordered  digestion,  constipation,  etc. 

Hypochondriacs  fall  asleep  when  they  go  to  bed,  but  they 
very  frequently  awake  between  three  and  five  in  the  morning 
(when  the  circulation  is  most  depressed)  in  a  state  of  perspira- 
tion, and  lie  in  abject  misery,  tortured  with  dreadful  forebod- 
ings till  the  hour  for  rising. 

It  is  of  course  necessary  to  search  for  organic  disease,  for 
a  man  may  be  hypochondriacal  when  he  is  really  ill,  as  well 
as  when  he  is  not.  Certain  ailments  also,  such  as  varicocele, 
and  various  diseases  of  the  rectum,  are  not  infrequent  sources 
of  this  affection,  and  the  successful  treament  of  these  ailments 
goes  a  long  way  to  bring  about  a  cure.  Many  cases  of  hypo- 
chondriasis  drift  into  insanity,  especially  if  there  be  any  heredi- 
t&ry  tendency  to  mental  disorder. 

Treatment. — The  causes  must  be  traced  out,  and  the  pa- 
tient's life  arranged  upon  a  physiological  basis.  If.  the  condi- 
tions under  which  he  has  been  living  are  inimical  to  health 
they  must  be  altered. 

The  excessive  use  of  tobacco,  alcohol,  and  tea  should  be  in- 
terdicted. Exhausting  and  debilitating  practices  must  be 
abandoned,  and  in  women,  uterine  and  menstrual  disorders 
rectified;  although  this  must  not  be  undertaken  rashly,  as 
many  improve  more  quickly  and  permanently  by  treating  the 
general  health,  and  distracting  the  patient's  attention  from 
her  local  conditions.  In  some  of  these  cases  the  treatment  is 
begun  at  the  wrong  end. 

When  there  is  any  tendency  to  neurotic  disease,  or  if  there 
be  a  gouty  or  rheumatic  diathesis,  or  a  history  of  syphilis, 
these  morbid  states  afford  indications  for  treatment. 

The  state  of  the  blood-pressure  is  important.  It  is  said 
that  those  who  have  "low  tension"  make  bad  recoveries,  if 
they  recover  at  all;  while  those  who  have  well-marked  tension 
in  their  vessels  get  better  comparatively  easily. 

Here,  as  in  the  case  of  Irysteria,  it  is  most  desirable  to  ac- 
quire the  patient's  confidence,  so  as  to  inspire  him  with  hope, 
and  thus  secure  that  he  will  follow  implicitly  the  counsel  given 
him.  He  must  be  encouraged  to  cultivate  the  solace  of  healthy 
work,  that  his  preoccupied  mind  may  be  diverted  into  healthier 
channels,  and  new  psychical  centres  called  into  operation,  to 


io6  Insomnia  and  its  Therapeutics. 

the  relief  of  those  under  whose  dominion  he  has  been  living. 
Idleness  adds  greatly  to  his  wretchedness.  The  influence  of 
new  mental  conditions  is  well  seen  in  the  beneficial  results 
that  sometimes  accrue  from  marriage.  Some  years  ago  a 
professional  man,  the  victim  of  lithiasis,  consulted  the  writer, 
believing  he  had  an  aortic  aneurism.  So  convinced  was  he  of 
it  that  he  gave  up  his  business,  relinquished  his  literary  work, 
and  was  far  more  unhappy  and  distressed  than  if  he  really 
had  had  an  aneurism.  After  some  years,  falling  in  love  with 
a  lady  who  visited  his  house,  he  began  to  get  better,  married, 
and  is  now  in  robust  health,  a  happy  and  busy  man  both  in 
and  out  of  his  profession.  There  is  a  fair  sample  of  the  result 
of  mental  distraction,  though  the  high  arterial  tension  in  this 
case  was  a  factor  in  its  favor.  New  interests  are  to  be  sought 
in  change  of  air  and  scene,  conditions  calling  into  play  new 
psychical  centres,  at  the  same  time  invigorating  the  whole 
nervous  system.  Residence  in  a  bracing  but  not  too  exciting 
climate  is  to  be  advised,  or  at  one  of  the  many  spas,  either  at 
home  or  abroad,  where  amusements  and  social  advantages 
can  be  readily  obtained;  but  wherever  hypochondriacs  are 
sent  they  should  be  accompanied  by  a  judicious  and  cheerful 
companion.  Exercise  in  the  open  air  is  always  beneficial  in 
these  cases,  and  there  is  not,  as  in  neurasthenia,  much  to  be 
feared  from  over-exertion.  The  upper  limbs  should  be  em- 
ployed equally  with  the  lower  by  means  of  dumb-bells,  clubs, 
or  gymnastic  exercises,  so  that  at  night  the  body  will  be  all 
proportionately  tired. 

Hypochondriacs  mast  be  well  fed,  and  that  although  the 
tongue  is  furred  and  digestion  impaired;  these  conditions  im- 
prove with  good  feeding.  Extract  of  malt  and  cod-liver  oil 
may  be  given.  Stimulant,  except  in  every  expectional  cases, 
is  unsuitable,  and  had  better  be  avoided.  Bathing  in  the  sea, 
cold  sitz  baths,  cold  foot  baths,  Turkish  baths,  or  spinal 
douches,  may  be  ordered  in  suitable  cases. 

General  tonics,  as  arsenic,  quinine,  etc.,  may  be  tried,  and 
the  bowels  regulated  with  compound  galbanum  pills,  U.S. P., 
or  compound  asafcetida  pills.  Purgatives  appear  to  cause  in- 
creased sleep  disturbance  in  some  cases  by  giving  rise  to 
sensations  in  the  alimentary  tract  which  are  perceived  by  the 
hyper-sensitive  cerebral  cells.  The  addition  of  TT[  ij.  or  TT[  iij.  of 
the  oil  of  chamomile  flowers  prevents  this  occurrence.  In 


Insomnia  and  its   Therapeutics.  107 

such  cases  it  is  a  most  satisfactory  hypnotic.  It  lowers  re- 
flex excitability  in  a  very  marked  manner.  The  fresh  oil,  which 
has  a  greenish-blue  tint,  is  to  be  selected.  In  the  rheumatic, 
the  tincture  of  cimicifuga  in  3  ss.  doses  three  times  a  day  is 
of  value,  and  often  improves  sleep.  Electricity,  particularly 
central  galvanization  of  the  sympathetic,  is  worthy  of  a  trial. 

Sleep  is  of  the  first  importance.  Without  it  there  can  be 
no  improvement,  no  brain  recuperation,  no  increased  innerva- 
tion  of  the  heart,  etc.,  and  no  relief  from  the  morbid  depression. 
A  light  supper  at  bedtime,  and  some  warm  milk  or  beef-tea 
during-  the  night  or  toward  morning1,  are  useful.  Modified 
massage  before  going-  to  bed,  or  a  mustard  plaster  over  the 
abdomen  or  alone  the  spine  is  sometimes  serviceable.  A  hot 
bath  before  bedtime  may  be  tried.  In  certain  cases  it  an- 
swers admirabl3T;  though  its  effects  are  somewhat  uncertain, 
and  in  some  instances  it  intensifies  the  wakefulness. 

When  the  blood-tension  is  low  digitalis  and  ergotin  should 
be  given. 

3  Ergotin.,       .       .        .       .       .  .  .  gr.  i. 

Ext.  nucis  vom.,  .     .  f        *        .  .  .  gr.  ss. 

Pulv.  digital.,       .        .        .        .  .  .  gr.  i. 

Ft.  pil.  i.     Sig.  Take  one  thrice  daily. 

Or  else,  the  citrate  of  caffeine  in  doses  from  gr.  i.  to  gr.  iv., 
thrice  daily.  It  acts  powerfully  upon  the  vaso-motor  system, 
but  in  large  doses  it  causes  headache. 

When  the  blood-tension  is  abnormally  high,  calomel  and 
alkalies  with  aconite  suit  well.  {Vide  page  596.) 

When  there  is  cerebral  anaemia  the  chloride  of  gold  and 
sodium  in  doses  of  gr.  ^  to  gr.  ^  three  times  a  day  may  prove 
beneficial.  In  hypochondriasis  in  the  aged,  arsenic  should  be 
prescribed  in  one  or  other  of  its  varied  forms.  Cannabis  in- 
dica  lessens  depression  and  promotes  sleep;  from  gr.  ss.  to  gr. 
i.  may  be  given  thrice  daily,  the  last  dose  at  bedtime.  When 
some  decided  hypnotic  is  urgently  required  for  a  few  nights, 
paraldehyde,  chloral  hydrate,  with  potassium  bromide,  or  mor- 
phine with  atropine  may  be  used ;  but  as  those  medicines  all 
tend  to  retard  recovery,  by  interfering  with  digestion,  they 
must  if  possible  be  avoided.  A  well-shaded  lamp  in  the  bed-- 
room  is  sometimes  a  source  of  much  comfort,  and  in  so  far 
tends  to  promote  sleep. 


io8  Insomnia  and  its   Therapeutics. 

It  is,  however,  on  the  whole,  probable  that  perse veringly 
tiring-  the  mental  and  bodily  powers  day  by  day,  under  healthy 
and  bracing  conditions,  is  by  far  the  best  hypnotic. 

INSANITY. 

It  is  not  within  the  scope  of  this  work  to  deal  with  the 
great  subject  of  insomnia  connected  with  insanity;  nor  is  the 
writer  competent  to  undertake  such  a  task,  if  fee  would,  his 
experience  being  limited  to  the  preliminary  insomnia  which 
preludes  almost  every  form  of  insanity.  This,  of  necessity, 
comes  under  the  care  of  the  general  physician  in  the  earliest 
stages,  arid  at  a  time  when  the  want  of  sleep  may  be  the  sole 
indication  that  there  is  any  departure  from  perfect  health. 
The  following  remarks  will  be  restricted  chiefly  to  the  sleep- 
lessness which  occurs  at  the  onset  of  mania  and  melancholia, 
characterized,  as  these  conditions  are,  by  exaltation  and  de- 
pression of  feeling  respectively. 

Drs.  Bucknill  and  Tuke,  in  their  work  on  Psychological 
Medicine,  make  the  following  remarks :  "  Want  of  refreshing 
sleep  we  believe  to  be  the  frequent  origin  of  insanity,  depen- 
dent upon  moral  causes.  Very  often,  when  strong  emotion 
tends  to  the  production  of  insanitj7,  it  causes,  in  the  first  in- 
stance, complete  loss  of  sleep.  In  many  cases,  however,  the 
power  of  sleeping  is  not  lost,  but  the  quality,  so  to  say,  of  the 
function  is  perverted,  the  sleep  being  so  distracted  by  agoniz- 
ing dreams  that  the  patient  awakens  jaded  rather  than  re- 
freshed. We  have  known  several  instances  in  which  patients, 
becoming  convalescent  from  attacks  of  acute  mania,  have 
distinctly  and  positively  referred  to  frightful  dreams  as  the 
cause  of  their  malady;  and  it  is  probable  that  a  certain  qual- 
ity of  sleep,  in  which  dreams  excite  terror  and  other  depress- 
ing emotions  more  forcibly  than  waking  events  are  likely  to 
do,  is  scarcely  less  adverse  than  complete  insomnia  to  the 
nutritive  regeneration  of  that  portion  of  the  brain  on  whose 
action  those  emotions  depend.  In  such  a  condition  it  is  highly 
probable  that  the  very  portions  of  the  brain  which  most  need 
a  state  of  rest  are,  even  during  the  sleeping  quiescence  of  other 
portions,  more  wastefully  engaged  in  the  activitj7  of  their 
functions  than  they  could  be  in  the  waking  state.  The  main- 
spring of  insanity  is  emotion  of  all  kinds.  This,  stimulated  by 


Insomnia  and  its  Therapeutics.  109 

phantasy,  and  emancipated  from  the  control  of  judgment, 
during1  harassed  sleep,  may  be  more  profoundly  moved  than  at 
any  other  time." 

Thus  insomnia  alone  may  lead  to  insanity. 

It  will  be  useful  to  glance  at  a  classification  of  insanity. 
The  late  Dr.  Skae,  of  the  Royal  Edinburgh  Asylum  for  the 
Insane,  stated  it  thus :  "  Intellectual  and  moral  idiocy  and  im- 
becility. Insanity  with  epilepsy.  Insanity  of  masturbation 
and  pubescence.  Hysterical,  amenorrhceal,  post-connubial,  and 
puerperal  insanity.  Insanity  of  lactation  and  pregnancy. 
Climacteric,  ovarian,  hypochondrical,  senile,  phthisical,  metas- 
tatic,  and  traumatic  insanity.  Rheumatic,  podagrous,  and 
sj'philis  insanity.  Delirium  tremens.  Insanity  of  alcoholism. 
Malarious,  pellagrous,  and  post-febrile  insanity.  Insanity  of 
oxaluria.  Anaemic  and  choreic  insanity.  General  paralysis 
with  insanity.  Hereditary  insanity  of  adolescence.  Sthenic 
and  asthenic  idiopathic  insanity/'  This  classification,  for  all 
practical  purposes,  may  be  considered  as  a  list  of  diseases  and 
conditions  predisposing  to  insanity.  Among  the  exciting 
causes  may  be  enumerated  conditions  we  have  already  dis- 
cussed, such  as  overwork,  shock,  worry,  grief,  and  many  de- 
bilitating diseases  and  practices  referred  to  under  the  head  of 
neurasthenia;  states  productive  of  cerebral  exhaustion,  which, 
in  many  instances,  is  accelerated  by  an  increased  blood-supply, 
maintaining  activity  in  the  already  enervated  centres. 

The  predisposing  and  exciting  causes  of  insanity  are  worthy 
of  study,  for  they  embrace  a  vast  number  of  diseases  and  con- 
ditions which  occasion  insomnia,  and  that  without  insanity 
supervening.  •  The  explanation  of  this  is  to  be  found  in  the 
stamina  of  the  nervous  textures.  Circulatory  modifications 
and  defective  nutritive  changes  in  the  brain  may  in  those  with 
stable  nervous  centres  cause  merely  insomnia;  and  in  others 
with  unstable  nervous  tissues,  pathological  changes  which 
end  in  insanity.  It  is  important  never  to  overlook  the  fact 
that  insomnia,  occurring  in  connection  with  any  of  these  ab- 
normal states,  may  be  in  reality  the  premonitory  symptom  of 
insanity.  The  early  recognition  of  this  truth  not  infrequently 
enables  the  physician  to  successfully  avert  its  development. 

Insomnia  occurring  without  apparent  cause,  particularly 
in  those  who  have  an  hereditary  tendency  to  insanity,  and 
whose  general  health  is  deteriorated,  must  ever  be  regarded 


HO  Insomnia  and  its   Therapeutics. 

with  suspicion,  as  a  prodroma  of  mental  disease.  It  demands 
the  same  vigilant  and  careful  treatment  that  it  would  receive 
if  the  diagnosis  were  more  definite,  for  pronounced  mental 
diseases  may  develop  suddenly,  and  be  accompanied  by  sui- 
cidal and  homicidal  tendencies.  Indeed  many  tragedies  have 
been  enacted  in  instances  where  the  sole  exciting  cause,  and 
the  only  precursory  symptom,  was  insomnolency. 

Dreams  are  common  precursors  of  insanity,  and  at  times 
(depending  upon  activity  smaller  in  degree)  they  anticipate  in- 
somnia. The  recurrence  of  a  peculiar  and  unusual  dream 
night  after  night,  particularly  if  it  is  of  a  terrifying  kind, 
should  always  arouse  suspicion. 

When  consulted  by  a  well-known  patient  for  insomnia,  at 
the  commencement  of  an  attack  of  mental  disease,  important 
assistance  can  be  obtained  in  forming  a  diagnosis,  by  consid- 
ering the  family  history,  sex,  age,  station,  and  occupation,  as 
well  as  the  altered  aspect  and  bearing  almost  certain  to  be 
present,  and  the  perversion  of  feeling  often  displayed.  A 
little  tact  will  elicit  a  confession  of  some  delusion,  illusion,  or 
hallucination  which  occurs  during  waking  moments,  and  which 
the  patient  strives  cunningly  to  conceal. 

It  is  more  difficult  when  the  patient  is  unknown,  for  the 
change  in  appearance,  manner,  and  demeanor  may  be  so  slight 
as  to  elude  detection;  in  which  case,  some  reliance  must  be 
placed  upon  the  statements  of  relatives  and  friends.  This  is 
specially  desirable  when  their  evidence  points  in  the  direction 
of  altered  habits  and  disposition  referable  to  the  emotional 
rather  than  to  the  intellectual  centres. 

Mania  may  be  ushered  in  by  sleeplessness,  and  by  a  condi- 
tion of  depression  which  gives  way  to  exaltation.  It  is  usually 
accompanied  by  a  certain  amount  of  cerebral  hyperasmia, 
which  causes  headache,  flushing  of  the  face,  suffusion  of  the 
e3res,  a  raised  temperature,  and  throbbing  of  the  arterial  ves- 
sels. It  is  not  suggested  that  cerebral  hyperaemia  is  the  cause 
of  the  mania,  but  it  is  probable  that  it  is  an  important  factor 
in  the  production  of  sleeplessness;  as  well  as  being  unfavor- 
able for  brain  nutrition,  which  of  itself  tends  to  increase  the 
abnormal  condition  of  the  brain.  Hypersemia,  when  asso- 
ciated with  exhaustion  in  the  emotional  and  volitional  centres, 
renders  them  extremely  irritable  and  excitable,  and  causes 
them  to  discharge  their  energy  upon  the  slightest  provoca- 


Insomnia  and  its   Therapeutics.  \\\ 

tion  and  to  dominate  over  the  higher  or  intellectual  centres; 
hence  the  extravagant  behavior  and  boisterous  conduct  of 
maniacs.  Sleep  may  be  absent  for  days  and  nights,  and  the 
lack  of  it  hastens  the  development  of  pronounced  symptoms. 
Occasionally  the  patient  tries  to  keep  awake  in  consequence 
of  terrifying-  dreams.  No  improvement  can  take  place  with- 
out sleep,  and  any  favorable  change  is  preceded  by  it. 

Treatment. — Complete  abstention  from  business  must  be 
insisted  upon,  and  all  sources  of  excitement  removed,  so  that 
mental  rest,  so  far  as  that  is  possible,  may  be  secured. 

The  bowels  must  be  thoroughly  unloaded  by  a  brisk  purga- 
tive; the  following  is  a  valuable  formula  for  a  robust  man: 

]J  Res.  scammon., gr.  v. 

Subchlor.  hydrarg.,      .        .        .        .        .  gr.  v. 

Pulv.  jalap., gr.  v. 

Supertart.  potass., gr.  v. 

Ft.  pulv.  i.     Sig.  Take  at  once. 

It  usually  acts  well,  but  if  it  fails  to  do  so  it  may  be  fol- 
lowed in  six  hours  by  some  sodium  sulphate.  The  application 
of  a  few  leeches  to  the  temples  or  behind  the  ears  is  to  be 
recommended;  as  also  an  ice  cap,  or  the  use  of  cold  evapor- 
ating lotions.  When  it  is  possible,  the  patient  maj7  spend  a 
considerable  portion  of  the  day  in  the  open  air,  walking  or 
driving  with  a  suitable  companion,  exercise  and  fresh  air  being 
useful  adjuncts  to  treatment.  Cases  which  are  not  pronounced, 
or  which  have  begun  to  recover,  are  sometimes  benefited  by 
change  of  air  and  scene  under  judicious  guidance  and  super- 
vision. The  resort  selected  must  have  a  sedative  climate,  and 
be  quiet.  Stimulating  seaside  residences  and  places  where 
gayety  prevails  should  be  eschewed. 

The  food  must  be  generous,  the  meals  large  and  frequent; 
a  foul  state  of  the  tongue  is  no  centra-indication  to  this.  Malt 
extract  or  pepsin  to  aid  digestion,  with  sound  ale  or  stout, 
sometimes  afford  good  results. 

Baths  are  of  special  service  when  the  patient  can  be  in- 
duced to  take  them  quietly.  The  hot  bath  prolonged  for  some 
time  before  going  to  bed,  with  cold  applications  to  the  head, 
is  usually  sleep-inducing.  Dr.  Newington  has  got  good  re- 
sults from  hot  mustard  baths.  These  full  baths,  however, 
should  never  be  administered  except  in  the  presence  of  the 


112  Insomnia  and  its   Therapeutics. 

medical  attendant.  The  wet  pack  may  be  employed  if  the 
full  bath  cannot  be  conveniently  used.  Hot  foot  baths — plain 
or  with  mustard — are  excellent  derivatives.  Besides  these 
applications  it  is  highly  desirable  to  insure  sleep  by  the  use 
of  hypnotics ;  no  time  must  be  lost,  treatment  to  be  efficient 
must  be  prompt  and  decidedly  energetic.  Chloral  hydrate  is 
very  suitable  in  such  cases;  its  action  is  promoted  by  lithium 
bromide. 

3  Chloral  hydrat.,          .        .        .   gr.  xl.  vel  gr.  Ix. 

Lithii  brom., 3ij. 

Syr.  tolu., 3  ij. 

Aquam, ad  §  ij. 

M.  Sig.  Take  one-half  an  hour  before  bedtime,  and  the 
other  half  in  an  hour  afterward. 

Hydrobromate  of  hyoscine  is  highly  praised;  it  is  said  to 
rapidly  induce  sleep  of  sveral  hours'  duration  without  any 
bad  effects,  even  in  the  midst  of  great  excitement.  It  is  best 
administered  hypodermically  in  doses  ranging  from  -yfaj-  of  a 
grain  to  T^7  of  a  grain.  Urethane  and  paraldehyde  are  reli- 
able remedies.  Occasionally  morphine  is  called  for;  it  should 
be  given  in  doses  of  from  ^  to  £  of  a  grain  in  combination  with 
£  of  a  grain  of  tartar  emetic.  If  with  the  return  of  sleep  the 
mental  condition  does  not  speedily  improve,  the  patient  should 
be  sent  to  a  retreat,  for  improvement  takes  place  more  quickly 
if  sent  early,  and  it  is  difficult  to  secure  proper  conditions  for 
treatment  at  home.  Active  treatment  will  render  removal 
unnecessary  in  many  cases,  but  it  must  not  be  carried  on  too 
long. 

Melancholia. — It  is  often  difficult,  at  first,  to  distinguish 
between  depression  of  spirits,  hypochondriasis,  and  melan- 
cholia, so  very  imperceptibly  do  these  conditions  glide  from 
one  into  the  other;  each  being  characterized  by  mental  de- 
pression and  by  an  enfeebled  state  of  the  bodily  health. 

Melancholia,  however,  is  always  attended  by  some  cerebral 
change,  probably  depending  in  most  cases  on  cerebral  exhaus- 
tion, and  accompanied  by  a  certain  amount  of  anosmia.  It 
differs  in  one  essential  respect  from  hypochondriasis,  in  that 
the  victims  are  usually  apathetic  about  what  happens  to 
them,  though  th?y  are  extremely  miserable ;  while  hypochon- 
driacs are  tenacious  of  life,  and  appear  never  to  weary 


Insomnia  and  its   Therapeutics.  1 1 3 

searching1  for  health.  Melancholies  are  not  so  sleepless  as 
maniacs,  yet  the  want  of  sleep  is  often  an  early  and  prominent 
symptom.  They  do  not  readily  sleep,  and  if  they  do,  they 
awake  soon  to  be  tormented  by  the  vilest  misery  that  it  is 
possible  for  human  creatures  to  endure.  Well-directed  treat- 
ment at  its  onset  is  often  attended  by  good  results;  it  is  fre- 
quently efficacious  in  averting  the  necessity  of  removal  to  a 
retreat. 

Treatment. — All  that  was  written  upon  the  subjects  of 
mental  rest,  food,  stimulant,  exercise,  change  of  air  and  scene, 
etc.,  when  discussing  the  question  of  neurasthenia,  might  be 
re-written  here.  Probably  a  larger  amount  of  stimulant  is 
called  for,  generous  wines  being  admissible,  such  as  sound 
Burgundy  and  claret.  In  choosing  a  health  resort,  the  more 
bracing  are  indicated.  Turkish  baths  afford  good  results  in 
Overcoming  the  melancholy,  and  they  promote  sleep.  Dr. 
Clouston  speaks  highly  of  them  as  a  means  of  cure  when  the 
affection  has  developed.  Mustard  plasters  over  the  stomach 
at  night  are  to  be  advised;  night  feeding,  e.g.,  milk  or  beef- 
tea  with  a  spoonful  of  rum  once  or  twice  during  the  night, 
promotes  sleep. 

Tonics  of  all  kinds  are  called  for,  arsenic,  quinine,  strych- 
nine, etc.  In  anaemic  cases  the  syrup  of  the  phosphates  of 
quinine,  strychnine,  and  iron,  in  3  i.  doses  thrice  daily  after 
meals,  in  water,  is  excellent.  Malt  extract  and  cod-liver  oil 
after  meals  are  useful.  Furring  of  the  tongue  is  no  hindrance 
to  increased  feeding;  on  the  contrary,  rather  an  indication 
for  it. 

The  bowels  must  be  attended  to;  mild  warm  laxatives 
being  preferred  to  salines. 

For  several  nights  at  least  sleep  must  be  secured  Toy  hyp- 
notics, the  best  being  morphine  with  atropine,  by  hypodermic 
injection.  Sulphonal  and  paraldehyde  are  both  useful,  as  is 
chloral  hydrate,  and  camphor  with  cannabis  indica  is  a  good 
combination. 

B  Camphor., gr.  ij. 

Ext.  cannab.  ind., gr.  ss. 

Ext.  hyoscy., gr.  iij. 

Ft.  pil.  i.     Sig.  Take  at  bedtime. 

In  all  cases  suicide  should  be  guarded  against,  and  the 
treatment  at  home  ought  not  to  be  persevered  in  too  long. 


1 14  Insomnia  and  its  Therapeutics. 

MYXCEDEMA. 

In  the  report  of  the  Committee  of  the  Clinical  Society  of 
London,  nominated  to  investigate  the  subject  of  myxredema, 
published  in  1888,  it  is  stated:  "In  a  large  proportion  sleep  is 
noted  as  good,  but  in  many  of  these  there  is  excessive  somno- 
lence, especially  in  the  daytime.  In  about  one-third  of  the 
cases  wakefulness  is  recorded,  and  sleep  is  often  disturbed  by 
horrible  dreams  and  sensations.  It  may  be  noted  that  drowsi- 
ness during  the  day  is  very  common  in  myxoedema  in  both 
good  and  bad  sleepers/* 

In  a  case  the  writer  had  under  his  care  some  years  ago,  in- 
somnia was  a  prominent  and  troublesome  symptom,  and  the 
sleep  that  was  obtained  was  restless  and  disturbed  by  fright- 
ful dreams.  He  tried  many  remedies  for  its  relief,  but  found 
none  efficacious  except  morphine.  His  limited  experience  does 
not  warrant  him  in  saying  more  upon  the  subject. 


CHAPTER  VI. 

INSOMNIA  DEPENDING  UPON  AFFECTIONS  OF  THE 
NERVOUS  SYSTEM—  Continued. 

INSOMNIA  DEPENDING  UPON  SPASMODIC  NEUROSES. 

CHOREA  is  a  functional  disorder  of  the  motor  centres  of 
the  brain,  initiated  by  faulty  nutrition  arising1  in  many  diverse 
ways.  It  may  be  brought  about  by  hyperaemic  and  anaemic 
conditions;  modifications  of  arterial  tension;  toxic  states  of 
the  blood,  as  in  rheumatism;  valvular  diseases  of  the  heart; 
pregnancy;  strains,  as  in  overwork;  and  shock,  as  in  fright. 
It  occurs  most  frequent! y  in  those  whose  nervous  systems  are 
susceptible  to  impressions;  whose  nutrition  is  materially  de- 
teriorated ;  and  who  have  a  hereditary  tendency  to  neurotic 
disease.  In  about  one-half  of  all  the  cases  it  is  excited  by 
fright,  depressing  emotions,  and  mental  overwork;  and  these 
affect  females  and  males  in  the  proportion  of  three  to  one 
(p.  565). 

Sleeplessness  exists  to  a  greater  or  less  extent  in  all  cases, 
and  not  relatively  to  the  severity  of  the  movements,  although 
these  manifestly  influence  it.  On  the  other  hand,  the  depth 
of  the  sleep  exerts  a  powerful  influence  over  the  movements. 
When  it  is  sound  they  usually  entirely  cease.  In  slight  cases, 
sleep  is  uneasy  and  restless,  though  the  movements  are  com- 
pletely arrested.  In  more  pronounced  cases  there  is  difficulty 
in  getting  off  to  sleep,  and  when  sleep  follows,  it  is  broken  and 
disturbed  by  alarming  dreams  which  cause  the  patient  to 
awake  in  terror;  in  the  worst  forms  of  the  disease,  sleep  is 
sometimes  impossible,  and  when  death  occurs  it  is  mainly  due 
to  this  complication.  Choreic  insanity  is  always  heralded  b.y 
insomnia. 

Treatment. — The  patient  must  be  carefully  guarded  from 
all  mental  shock  and  strain ;  well  nourished  with  simple  and 
light  food ;  encouraged  to  spend  as  much  time  as  possible  in 


1 1 6  Insomnia  and  its   Therapeutics. 

the  open  air,  and  to  practise  systematic  gymnastic  exercises. 
When  the  attack  is  at  all  pronounced,  it  is  well  to  keep  the 
sufferer  in  bed,  as  there  he  improves  more  quickly.  Tonics, 
such  as  arsenic,  strychnine,  etc.,  are  always  indicated.  Anti- 
pyrine,  which  has  lately  come  into  use  in  the  treatment  of 
this  disease,  appears  to  influence  sleep  favorably;  the  dose  is 
from  five  to  .eight  grains  three  times  a  day. 

Warm  baths,  wet  packs,  or  modified  massage  toward  bed- 
time are  each  useful  in  promoting  sleep. 

Alcohol  in  the  form  of  white-wine  whey  acts  beneficially  in 
almost  every  case,  equalizing  and  tranquillizing  the  cerebral 
circulation,  and  often  cutting  short  the  disease. 

When  there  is  cerebral  hyperaemia,  mild  purgatives  are 
useful  derivatives.  To  promote  sleep,  which  is  the  most  cura- 
tive of  all  agents,  monobromide  of  camphor  may  be  given  in 
two-grain  doses  at  4  and  8  P.M.  The  following  also  suits  well 
in  more  severe  cases : 

IJ   Chloral  hydrat., 3  i.  vel  3  iss. 

Potass,  brom., 3  ij. 

Syr.  tolub., 3  vi. 

Aquam, ad  §  vi. 

M.  Sig.  Take  a  tablespoonful  in  water  two  hours  before 
bedtime,  and  again  at  bedtime. 

In  anaemic  conditions  of  the  brain,  alcohol  must  be  freely 
pushed  to  a  point  short  of  intoxication,  and  from  5  to  10 
minims  of  the  solution  of  acetate  of  morphine  given  for  sev- 
eral successive  nights.  All  these  remedies  are  suitable  for 
children  between  eight  and  ten  years  of  age. 

The  value  of  sleep  in  the  treatment  of  severe  chorea  has 
lately  been  emphasized  by  Dr.  Charlton  Bastian,  and  Professor 
Gairdner,  of  Glasgow  ("  Lancet,"  1889).  It  is  of  equal  value 
in  every  form  of  the  disease,  and  that  it  should  be  so  is  obvi- 
ous from  the  fact  that  sleep  is  the  time  favorable  for  the  re- 
cuperation of  the  nervous  system. 

Paralysis  Agitans. — Sleeplessness  may  occur  at  the  very 
beginning  or  in  the  premonitory  stage  of  this  disease,  before 
tremor  has  been  noticed  at  all.  Slight  weakness  of  the  limb 
may  be  the  only  symptom,  and  that  only  after  using  it,  per- 
haps discernible  in  the  right  hand  alone,  after  writing.  It 
mav  occur  also  in  connection  with  neuralgic  and  so-called 


Insomnia  and  its  Therapeutics.  117 

rheumatic  pains,  which  occasionally  mark  the  onset  of  the 
illness. 

When  the  disease  has  developed,  sleeplessness  may  depend 
upon  various  abnormal  sensations  seldom  absent,  and  which 
always  distress  the  patient,  e.g.,  stiffness  and  rigidity  of  the 
muscles  of  the  head  and  neck;  stiffness  and  tension  of  various 
muscles  of  the  trunk,  rendering-  voluntary  movements  diffi- 
cult. These  are  most  noticeable  and  troublesome  at  night, 
for  they  prevent  the  patient  changing  his  position  in  bed,  and 
the  constant  desire  to  move  about  or  to  turn  round,  combined 
with  the  inability  to  accomplish  it,  induces  an  irritability  well- 
nigh  intolerable.  Sensations  of  heat,  chiefry  referred  to  the 
back  and  epigastrium;  are  complained  of,  and  perspirations 
which  lead  to  tossing  off  the  bedclothes. 

Sleeplessness  may  likewise  be  due  to  the  visceral  disorders 
to  which  these  patients  are  liable,  owing  to  their  inability  to 
take  exercise.  During  the  earlier  stages  of  the  disease  the 
trembling  movements  cease  during  sleep,  but  in  the  later 
stages  the  movements  may  interfere  with  sleep ;  while  the  de- 
clining bodily  nutrition  and  the  increasing  nervous  exhaustion 
invariably  do  so. 

Mental  influences  aggravate  tremor  and  increase  sleepless- 
ness, but  the  latter  is  due  more  to  the  fatigue  following  the 
severe  paroxysms  of  shaking  than  to  the  mental  perturbation. 
Almost  every  case  of  paralysis  agitans  that  the  writer  has 
met  with  in  practice,  has  occurred  in  persons  who  had  always 
been  bad  sleepers.  At  present  he  has  under  his  care  such  a 
case,  a  gentleman  aged  fifty-eight  years,  who  has  been  afflicted 
with  the  complaint  for  eight  or  nine  years,  and  whose  most 
troublesome  symptom  is  want  of  sleep.  Throughout  his  life, 
though  he  has  worked  as  hard  as  it  was  possible  for  any  man 
to  work,  and  has  rendered  signal  service  to  his  country  in 
more  than  one  department,  he  has  not  slept  on  an  average 
more  than  four  or  five  hours  a  night. 

Treatment. — The  food  and  stimulant  must  be  carefully 
regulated,  especially  that  taken  at  the  last  meal  of  the  day; 
and  all  disorders  of  digestion  and  constipation  remedied. 
Change  of  air  and  frequent  change,  suited  to  the  temperament 
of  the  patient,  does  much  to  improve  sleep.  The  patient's  bed 
should  be  such  that  he  may  repose  comfortably,  and  be  able 
to  change  his  position  with  as  little  difficulty  as  possible;  an 


1 1 8  Insomnia  and  its  Therapeutics. 

iron  or  brass  bedstead  with  an  unyielding-  hair  mattress  suits 
best.  It  is  always  a  comfort  having  some  one  sleeping  in  an 
adjoining1  room  to  assist  the  patient  in  turning  if  required. 

If  it  is  necessary  to  resort  to  special  treatment  for  sleep- 
lessness, galvanization,  mustard  over  the  epigastric  region, 
modified  massage,  and  hot  foot-baths,  are  each  useful.  Hyp- 
notics are  occasionally  required  for  four  or  five  nights,  for  the 
purpose  of  forming  a  better  sleeping-habit.  Paraldehyde  in 
full  doses  at  bedtime  is  exceedingly  useful.  Also, 

5   Chloral  hy drat.,    ...        .        .        .    3iiss. 

Potass,  bromid., 3  i. 

Liq.  morph.  acet.,         .        .        .        .        .    3  ss. 

Syr.  aurant.,          .        .        .        .        .        .    3  i. 

Aquam,          .        .        .        .        .        .      ad  §  iij. 

M.  Sig.  Take  one-half  at  bedtime  and  the  other  in  two 
hours  if  required. 

Sulphonal  in  20-grain  doses,  acted  extremely  well  in  one 
case.  Occasionally  remedies  directed  to  the  cure  of  the  dis- 
ease, by  controlling*  tremor,  improve  the  power  of  sleep,  but 
this  is  not  always  so.  In  a  recent  case  ^  of  a  grain  of  hyos- 
cyamine  was  prescribed  twice  daily;  its  physiological  effects 
speedily  and  markedly  manifested  themselves — dilatation  of 
the  pupil,  dryness  of  the  mouth  and  throat,  noises  in  the  ears, 
confusion  of  thought,  delusions,  incoherent  speech,  and  giddi- 
ness ;  but,  although  the  tremor  literally  disappeared,  the  in- 
somnia was  aggravated. 

Dr.  Taylor,  of  Lower  Tooting,  kindly  brought  under  the 
writer's  notice  a  case  of  many  years'  duration,  which  was 
complicated  with  spasmodic  wry-neck,  where  both  affections 
yielded  to  the  use  of  scutellaria  continued  perseveringly  dur- 
ing nine  months. 

Spasmodic  Wry-Neck. — When  the  spasmodic  movements 
which  accompany  this  affection  do  not  cease  during  sleep, 
considerable  relief  may  be  obtained  from  a  specially  con- 
structed pillow,  assisting,  as  it  does,  to  control  the  movements. 

INSOMNIA  PROM  PAROXYSMAL  NEUROSES. 

Epilepsy. — Many  epileptics  suffer  from  sleeplessness. 
Restlessness  and  disturbed  sleep  prelude  the  attacks  equally 
with  sound  sleep. 

i 


Insomnia  and  its   Therapeutics.  1 19 

Among-  the  predisposing-  causes  of  epilepsy,  the  most  fre- 
quent is  a  tendency  to  neurotic  disease;  while  among1  the  ex- 
citing causes  are  some  which  we  have  already  considered  as 
sources  of  insomnia.  For  example,  Dr.  Russell  Reynolds  found 
that  in  twenty-seven  cases  out  of  sixty-three  the  disease  was 
excited  by  fright,  grief,  worry,  and  overwork;  and  Dr.  Gowers 
found  that  fright  caused  10  per  cent  of  all  the  cases  he  in- 
vestigated— under  the  age  of  ten  years,  in  males  and  females 
in  equal  proportions,  and  between  ten  and  twenty  years  in  the 
proportion  of  three  males  to  four  females. 

The  pathology  of  epilepsy  has  not  yet  been  definitely  as- 
certained, but  it  is  generally  believed  that  in  the  initial  stage 
of  the  seizure  there  is  profound  cerebral  anaemia ;  for  besides 
the  marked  pallor  of  the  face,  Dr.  Hughlings  Jackson  found 
on  ophthalmoscopic  examination  that  the  retinas  were  blood- 
less. This  accords  with  the  convulsions  which  attend  acute 
cerebral  anaemia  from  sudden  and  profuse  bleedings,  but  the 
exciting  cause  of  this  anaemia  in  epilepsy  is  still  a  mystery.  It 
seems  not  unreasonable  to  argue  that  the  conditions  which 
give  rise  to  it,  and  cause  epilepsy,  acting  in  a  less  degree  may 
excite  a  modified  cerebral  anaemia  sufficient  to  account  for 
wakefulness. 

Such  cases  of  insomnia  are  easily  enough  recognized  where 
there  is  a  history  of  epilepsy,  but  if  there  is  not,  the  cause  may 
elude  detection;  for  the  seizures,  the  petit  mal  and  the  haut 
mal,  may  occur  only  during  sleep,  and  their  existence  be  un- 
suspected, the  patient  himself  having  no  knowledge  or  recol- 
lection of  the  attacks.  He  usually  complains  of  languor,  pain 
in  the  back  and  in  the  muscles  of  the  body  generally,  fulness 
and  weight  in  the  head  in  the  morning,  which  requires  for  its 
removal  more  than  one  good  night's  sleep.  Should  his  tongue 
be  bitten,  or  petechial  spots  be  found  about  his  head,  neck,  or 
chest,  or  if  he  has  passed  his  urine  unconscious^  in  bed,  and 
has  been  heard  to  utter  a  piercing  cry,  the  diagnosis  will  be 
tolerably  clear.  A  little  care  will  suffice  to  trace  the  sleep 
disturbance  to  its  true  origin.  If  sound  sleep  does  not  follow 
the  epileptic  attack,  the  patient  may  become  irascible,  rest- 
less, and  even  violent  during  the  day,  and  sleepless  at  night, 
and  unless  proper  means  are  adopted,  this  may  continue  until 
a  severe  seizure  ensues. 

Treatment. — It  is  practically  that  of  the  disease.     The  rec- 


I2O  Insomnia  and  its  Therapeutics. 

ognition  of  the  causation  is  the  important  point.  The  pa- 
tient's life  must  be  carefully  considered  and  arranged,  for,  as 
the  late  Dr.  Latham  wrote:  "That  by  knowing1  what  a  man 
is,  and  how  he  lives  habitually,  the  physician  often  arrives  at 
a  much  better  judgment  and  a  better  treatment  of  his  dis- 
eases." All  debilitating-  practices  must  be  interdicted,  and  the 
exciting1  causes,  so  far  as  possible,  removed.  Food  should  be 
nutritious,  but  bland  and  unstimulating;  and  alcohol,  in  most 
cases,  should  be  dispensed  with.  Bathing1,  under  suitable  con- 
ditions, and  well  regulated  exercise,  are  useful  adjuncts  to 
treatment.  All  mental  strain  should  be  avoided.  It  is  said 
that  patients  are  less  liable  to  night  seizures  if  they  sleep  with 
the  head  well  raised  upon  a  high  pillow.  Sleep  in  these  cases 
is  certainly  improved  by  this,  and  one  patient,  who  was  for 
many  years  under  treatment,  seldom,  if  ever,  had  a  fit  during 
the  night,  except  when  his  head  got  off  the  pillow,  and  on  to 
the  same  level  as  his  body.  Sleeplessness  is  an  indication  for 
pushing  energetically  the  medication  of  this  affection. 

Whenever  altered  sleep  at  night,  or  changed  demeanor 
during  the  day,  indicates  an  approaching  fit,  3  I.  of  potassium 
bromide,  with  10  to  15  grains  of  chloral  hydrate,  may  be  given 
at  night  until  the  crisis  appears  to  be  passed.  Dr.  Russell 
Reynolds  thinks  belladonna  valuable  when  there  is  disturbed 
sleep.  In  two  cases  the  writer  believed  he  obtained  good  re- 
sults from  the  administration  of  nitrite  of  sodium  in  two-grain 
doses,  thrice  daity.  A  whiff  of  amyl  nitrite  improves  sleep. 

Migraine. — Sleeplessness  is  not  infrequently  met  with  in 
the  victims  of  this  distressing  complaint.  Much  has  been 
written  concerning  the  pathology  of  migraine.  The  writer  is 
disposed  to  accept  Dr.  Liveing's  view,  that  it  is  practically  a 
nerve  storm,  the  condition  arising  from  the  irregular  accumu- 
lation and  erratic  discharge  of  nerve  energy  bringing  about 
anaemic  and  hyperaemic  states  of  the  brain.  "A  nerve-storm 
traversing  more  or  less  of  the  sensory  tract  from  the  optic 
thalami  to  the  ganglia  of  the  vagus,  or  else  radiating  in  the 
same  tract  from  a  focus  in  the  neighborhood  of  the  quaclri- 
geminal  bodies."  As  it  was  argued  in  connection  with  epi- 
lepsy, so  the  theory  may  be  advanced  here,  that  these  causes, 
acting  in  a  less  degree,  may  give  rise,  not  to  migraine,  but  to 
disturbed  sleep.  The  predisposing  and  exciting  causes  of  mi- 
graine are  closely  allied  to  those  of  insomnia.  Among  the 


Insomnia  and  its   Therapeutics.  121 

former  are  hereditary  tendency,  neurotic  temperament,  and 
adynamic  states  of  the  system;  and  among-  the  latter,  over- 
work, excitement,  depressing-  emotions,  excesses  of  all  kinds, 
and  curtailment  of  sleep.  When  the  attacks  are  severe  they 
prevent  sleep. 

Treatment. — Everything  tending  to  promote  good  sleep 
and  to  establish  the  patient's  health  on  the  highest  level  be- 
tween the  attacks  should  be  aimed  at.  The  details  of  the 
daily  life  ought  to  be  arranged  so  that  the  food,  mental  work, 
and  corporeal  exercise  should  bear  relation  the  one  to  the 
other,  and  be  in  proportion  to  the  strength.  Turkish  baths 
or  the  needle  or  spray  baths  are  often  suitable.  Alcohol  is 
best  avoided  by  the  majority;  in  the  smaller  number  it  must 
be  carefully  prescribed. 

Cannabis  indica,  with  valerianate  of  zinc,  taken  for  a  time, 
improves  sleep  and  controls  the  attacks. 

$  Ext.  cannab.  ind., gr.  ss. 

Valerian,  zinc., gr.  ij. 

Ext.  gentian., q.  s. 

Ft.  pil.  i.     Sig.  Take  one  pill  twice  or  thrice  daily. 

When  the  attack  threatens,  ten  grains  of  antipyrine  may 
be  given  every  thirty  minutes  for  four  doses;  or  two  grains 
of  the  citrate  of  caffeine  in  a  little  aerated  water,  the  patient 
lying  quiet,  in  a  darkened  room,  with  a  hot  bottle  to  the  feet, 
and  a  mustard  and  linseed  poultice  over  the  stomach.  Dr. 
James  Little  advocates  the  addition  of  twenty  grains  of  so- 
dium salicylate  to  the  citrate  of  caffeine,  to  be  repeated  in 
two  hours  if  required.  Should  these  remedies  not  improve 
sleep,  paraldehyde  or  bromidia  may  be  given  at  bedtime  for 
a  few  nights.  When  the  attack  of  migraine  is  so  severe  as 
to  prevent  sleep,  -£-  of  a  grain  of  morphine  tartrate  with  -j-^ 
of  a  grain  of  atropine  may  be  administered  hypodermically ; 
or  if  morphine  is  contra-indicated,  from  five  to  ten  grains  of 
butyl-chloral  hydrate  should  be  given  in  some  syrup  and 
water. 

Nightmare. — In  this  disorder,  as  well  as  in  night-terrors 
and  somnambulism,  there  are  unequal  degrees  of  "  particular 
sleep  "  (p.  502)  in  the  cerebral  centres,  ca.using  disturbance  of 
"general"  and,  probably,  of  unusually  sound  sleep. 

Nightmare   is  brought   about  by  a   vivid   and   alarming 


122  Insomnia  and  its  Therapeutics. 

dream,  implying1  great  activity  in  some  of  the  ps3rchical  cen- 
tres, while  the  motor  centres  are  slumbering4.  The  dream  is 
usually  of  such  a  nature  as  to  impress  the  sleeper  with  a  most 
painful  sense  of  immediate  bodily  danger,  from  which  he  should 
instantly  extricate  himself.  Unable  to  move,  his  agitation 
and  fright  increase,  until  he  wakes — perhaps  in  the  act  of 
groaning  or  shouting  for  help.  When  he  is  thoroughly  roused 
he  is  quite  free  from  all  discomfort,  and  relieved  to  find  his 
misery  has  been  caused  by  a  dream,  although  he  may  try  not 
to  fall  asleep  again,  for  fear  of  a  recurrence. 

The  most  frequent  exciting  cause  of  nightmare  is  disturb- 
ance in  the  gustro-intestinal  canal,  such  as  is  caused  by  eating 
indigestible  food,  or  by  drinking  a  variety  of  wines  at  a  late 
dinner  shortly  before  retiring  to  bed.  It  is  sometimes  due  to 
an  exhausted  or  neurasthenic  state  of  the  nervous  system,  and 
it  is  liable  to  occur  in  persons  of  gouty  habit. 

Treatment. — The  general  health  must  be  attended  to,  the 
diet  regulated,  the  bowels  unloaded,  and  the  sleeping  condi- 
tions improved,  if  they  are  in  any  way  defective.  Potassium 
bromide  may  be  given  for  several  nights  in  3  ss.  to  3  i-  doses, 
to  equalize  and  tranquillize  the  cerebral  circulation. 

Night-terrors. — Closely  allied  to  nightmare,  but  differing 
from  it  in  its  pathology,  is  the  condition  known  as  night- 
terrors.  It  is  commonly  met  with  in  children  between  the 
ages  of  one  and  four  years  who  are  the  victims  of  dreams, 
which  appear  to  affect  the  cerebral  centres  of  emotion  to  a 
greater  extent  than  the  higher  centres. 

The  pathognomonic  symptom  is  that  they  wake  within 
the  first  two  hours  of  sleep,  when  it  is  deepest,  in  a  state  of 
great  agitation,  screaming,  violently,  and  evincing  a  strong 
desire  to  get  away  from  something  (as  a  wild  animal),  which 
they  evidently  think  is  attacking  them;  they  beseech  their 
father  or  mother  to  remove  it,  and  fail  to  recognize  the  parent 
they  are  entreating,  who  may  at  the  very  time  have  the  child 
in  his  arms.  As  the  centres  of  consciousness  awake  the  child 
realizes  its  happier  surroundings,  and  becomes  gradually  paci- 
fied, although  it  always  takes  some  time  to  restore  its  confi- 
dence, and  admit  of  its  falling  asleep.  This  terror  does  not 
often  recur  the  same  night,  though  it  is  liable  to  do  so  on 
those  which  follow. 

Dr.  Ringer,  in  his  "  Handbook  of  Therapeutics,"  points  out 


Insomnia  and  its   Therapeutics.  123 

that  squinting1  sometimes  occurs  along1  with  it,  and  that  it  may 
afterward  become  permanent. 

The  predisposing  cause  of  this  affection  is  an  impression- 
able and  excitable  nervous  system. 

The  exciting  causes  are  teething,  gastro-intestinal  derange- 
ments, whooping  cough,  febrile  disturbances,  and  improper 
sleeping  conditions. 

Treatment. — It  is  desirable  to  remove  or  relieve  the  excit- 
ing cause  of  the  attacks,  and  to  adopt  measures  for  invigor- 
ating the  nervous  system.  The  food  must  be  carefully  ar- 
ranged, so  as  to  avoid  over-  as  well  as  under-feeding.  The 
sleeping  room  ought  to  be  of  a  comfortable  temperature,  and 
thoroughly  ventilated,  and  the  bedclothes  light  and  warm. 
A  shaded  light,  and  the  presence  of  a  nurse  in  the  immediate 
vicinity,  are  great  comforts  to  a  nervous  child  in  going  to 
sleep,  giving  it  confidence,  and  preventing  its  emotional  from 
dominating  over  its  other  centres :  they  are  therefore  valuable 
prophylactics.  Where  digestive  derangements  are  present 
mild  laxatives  are  called  for. 

5   Pulv.  rhei, gr.  ij. 

Bicarb,  sodii, gr.  iij. 

Pulv.  aromat.  co.,          .        ...        •        •  gr-  i- 
Ft.  pulv.     Sig.  Take  one  twice  daily. 

The  bromides  are  very  valuable  in  these  cases,  and  Dr. 
Ringer  says  that  they  remove  the  squinting. 

5   Brom.  potass., 3  i. 

Syr.  aurant., 3  iij- 

Aquam, ad  §  vi. 

M.     Sig.  Give  a  tablespoonful  at  4  P.M  and  at  bedtime. 

A  warm  bath  should  likewise  be  given  at  bedtime.  If  the 
attacks  do  not  quickly  subside,  the  little  patient  should  be 
awakened  two  hours  after  falling  asleep,  so  as  to  prevent  sleep 
froni  becoming  too  profound. 

Somnambulism. — In  briefry  alluding  to  this  subject  in  the 
introductory  chapter,  it  was  pointed  out  that  the  state  de- 
pended upon  an  unequal  distribution  of  sleep,  and  that  it  in- 
volves certain  areas,  in  varying  degrees  of  depth.  Somnam- 
bulism is  virtually  an  acted  dream. 

It  may  take  the  form  of  sleep-crying,  sleep-talking,  sleep- 


124  Insomnia  and  its   Therapeutics. 

eating,  or  sleep-walking,  for  these  conditions  are  closely  allied 
to  each  other,  and  all  necessitate  correlated  muscular  move- 
ments. The  following1  remarks  have  reference  mainly  to 
sleep-walking,  in  which  the  movements  are  as  quickly  and  as 
unhesitatingly  performed  as  if  they  were  directed  by  con- 
sciousness, and  not  merely  taking  place  solely  under  the  do- 
minion of  the  basal  ganglia.  They  are  sensori-motor  acts; 
and  they  have  been  rightly  described  as  "  subhuman  rather 
than  superhuman/'  Somnambulists  having  conceived  their 
dream,  stage  it  so  precisely  that  they  are  able  to  act  it  with 
admirable  exactness.  Their  concentration  renders  them  ob- 
livious to  all  unconnected  objects  or  disturbing  agents,  so  that 
they  perform  as  well  in  a  dark  as  in  a  lighted  room,  and  with 
their  eyes  closed  as  well  as  open.  They  are  unconscious  of 
sounds  or  noises  not  associated  with  their  conception;  they 
may  be  shaken,  and  may  themselves  cough  and  sneeze  with- 
out being  awakened.  It  is  recorded  that  the  food  of  which 
they  were  partaking  has  been  changed,  and  that  their  snuff 
has  been  replaced  by  sawdust,  without  their  apparently  per- 
ceiving any  difference.  (Wood.) 

Among  the  predisposing  causes  of  somnambulism  must  be 
ranked  hereditary  tendency,  which  may  long  remain  unde- 
veloped, and  yet  appear  under  the  influence  of  exciting  causes. 
It  is  certainly  met  with  in  the  gouty,  and  in  those  of  neurotic 
temperament,  and  it  is  related  in  some  degree  to  hysteria, 
epilepsy,  and  catalepsy.  Most  common  in  youth,  it  affects  in 
almost  equal  proportion  males  and  females.  Dr.  Anstie 
("Lancet,"  1873)  wrote:  "Of  23  somnambulists  and  19  habit- 
ual sleep-talkers,  belonging  to  24  families,  12  somnambulists 
were  males  and  11  females,  13  sleep-talkers  were  males  and  6 
were  females."  It  commonly  disappears  when  adult  age  is 
attained;  when  it  does  not,  females  are  more  frequently  af- 
fected than  males.  The  worst  of  all  cases  are  those  occurring 
in  males  in  middle  age. 

The  exciting  causes  in  children  are  mental  excitement,  over- 
work, fright,  physical  exhaustion,  digestive  disturbances,  and 
an  overloaded  bladder. 

In  adults  it  arises  from  the  same  mental  causes,  derange- 
ments of  the  hepatic  and  digestive  functions,  and  over-eating 
and  over-drinking.  In  females  it  also  arises  from  uterine  and 
ovarian  disorders,  and  menstrual  irregularities. 


Insomnia  and  its  Therapeutics.  125 

It  is  said  to  arise  from  sleeping  with  the  head  low,  and  it 
must  be  added  that  it  may  occur  in  apparently  healthy  per- 
sons. Somnambulism  may  exist  in  various  degrees;  begin- 
ning as  simple  sleep-talking,  it  may  increase  till  it  ends  in 
sleep-walking.  At  first  the  sleeper  may  merely  rise  from  bed 
and  walk  round  the  room  to  perform  some  trifling  act,  and 
then  return  to  bed;  but,  as  the  habit  grows,  he  may  success- 
fully elude  articles  of  furniture,  unlock  doors,  open  windows, 
walk  out  of  doors,  along  dangerous  roofs  or  beside  the  edge  of 
precipices,  and  perform  feats  he  could  not  possibly  undertake 
during  waking  moments.  Cases  are  recorded  in  which  sleep- 
ers have  swum  across  rivers,  thrashed  corn,  ridden  on  horse- 
back, and  pursued  their  usual  daily  occupation. 

The  case  of  somnambulism  which  occurred  among  Dr. 
Guthrie  Rankin's  patients  is  worth  recording.  A  young  wo- 
man, worn  out  by  much  anxious  nursing,  lay  down  upon  her 
bed  with  her  clothes  and  slippers  on,  thoroughly  exhausted. 
By-and-by  she  rose  in  her  sleep,  left  the  house,  and  proceeded 
to  walk  across  the  country  through  fields  in  which  snow  lay 
a  foot  deep,  opening  gates  and  climbing  fences,  evidently  bent 
on  reaching  the  house  of  a  relative  some  miles  distant.  Being 
missed  from  her  room,  she  was  traced,  and  found  walking, 
almost  perished  with  cold,  in  a  deep  sleep.  There  appears  to 
be  a  certain  amount  of  anaesthesia  associated  with  sleep- 
walking. 

In  a  recent  case  the  patient  rose  from  his  bed,  and  dream- 
ing the  house  was  on  fire,  opened  the  window,  and  threw  him- 
self out.  The  rapidity  with  which  such  incidents  can  take 
place  is  somewhat  remarkable.  Another  patient  who  had  lost 
part  of  a  previous  night's  sleep,  was  left  by  his  visitors  in  the 
drawing-room  at  10  P.M.,  when  he  sat  down  to  read  by  the  aid 
of  a  lamp.  He  fell  asleep,  and  slumbered  until  awakened  by 
a  noise,  when  he  discovered  that  in  walking  about  the  room 
in  a  state  of  nudity  he  had  knocked  over  a  table.  It  was  just 
10 :30  P.M.  In  half  an  hour  he  had  read,  fallen  asleep,  con- 
ceived his  dream,  undressed,  folded  his  clothes  most  carefully, 
laid  his  socks  over  the  top  of  his  boots  (anything  but  his  usual 
custom),  extinguished  the  lamp,  and  started  on  his  peregrina- 
tions. So  far  as  he  is  aware  he  has  not  repeated  this  experi- 
ence, although  fully  twenty  years  have  elapsed. 

After  the  dream-act  is  concluded  the  actor  returns  to  bed, 


126  Insomnia  and  its   Therapeiitics. 

sleeps  until  his  usual  hour  for  rising  in  the  morning1,  and  when 
he  awakes  he  either  does  not  recollect  anything-  of  his  escapade, 
or  remembers  it  only  as  a  dream.  When  the  event  is  not  re- 
membered, it  may  recur  to  him  in  a  subsequent  somnambulis- 
tic state.  If  the  sleep-walker  is  awakened  incautiously,  he  is 
generally  much  agitated  and  frightened,  and  his  movements 
become  uncertain  and  clumsy.  Sleep-walking  leads  the  actors 
into  situations  which  endanger  life,  and  yearly  many  deaths 
are  recorded  from  accidents  so  arising,  and  terminating  fatally. 
Either  they  lack  the  dexterity  with  which  they  are  popularly 
credited  and  seem  to  possess,  or  awaking  at  a  critical  moment, 
coolness  and  precision  desert  them,  and  lead  them  to  ruin. 

The  subject  is  important  from  a  medico-legal  standpoint; 
indeed,  from  every  point  of  view  somnambulism  is  the  source 
of  much  anxiety  to  the  afflicted  and  to  their  relatives. 

Treatment. — Should  the  victim  be  found  in  his  wanderings, 
he  ought  not  to  be  awakened,  but  led  as  gently  as  possible 
back  to  bed,  abrupt  awaking  being  apt  to  give  rise  to  shock, 
which  may  mark  the  onset  of  other  nervous  diseases.  The 
prophylactic  treatment  is  important.  The  general  health 
must  be  attended  to,  and  all  neurasthenic  conditions  remedied. 
The  mind  and  the  body  should  be  daily  exercised  in  something 
like  relative  proportion,  undue  fatigue  or  excitement  of  either 
being  avoided.  The  food  must  be  light  and  nutritious,  late 
meals  shunned,  and  alcoholic  drinks  avoided  or  moderately 
used,  especially  toward  night.  The  bowels  should  be  regularly 
evacuated.  The  sleeping  room  should  be  cool,  the  mattress 
firm,  the  clothes  light,  and  the  pillow  well  raised.  Warm 
baths  should  be  taken  at  night,  and  Turkish  or  cold  sitz  baths 
during  the  day  are  beneficial  in  most  cases. 

If  in  spite  of  these  remedies  the  habit  continues,  it  may  be 
necessary  to  waken  the  sleeper  between  the  first  and  second 
hours  of  sleep,  when  it  is  deepest,  so  as  to  prevent  the  sleep 
becoming  too  profound.  Monobromide  of  camphor  may  be 
given  in  4-grain  doses  at  six  P.M.  and  at  bedtime.  In  some 
cases  it  is  necessary  to  chain  somnambulists  by  the  leg  to  the 
foot  of  the  bed,  and  in  all  to  see  that  the  doors  and  windows 
are  securely  fastened. 


CHAPTER  YIL 

INSOMNIA  DEPENDING  UPONS  AFFECTION  OF  THE 
NERVOUS  SYSTEM— Continued. 

FROM  AFFECTIONS  OF  THE  BRAIN  AND  ITS  MEMBRANES. 

IN  Chapter  II.  we  alluded  briefly  to  the  causation  of  active 
and  passive  cerebral  congestion,  and  of  cerebral  anaemia. 
This  must  be  taken  along-  with  the  following  remarks  upon 
their  S3rmptoms  and  treatment. 

Active  cerebral  congestion  or  hypercemia  exists  in  many 
degrees.  When  it  is  general  and  severe  it  may  speedily  pass 
into  the  more  pronounced  form  of  inflammation,  in  which  the 
early  symptoms  of  headache  and  insomnia  are  replaced  by 
those  of  stupor  and  coma.  It  is  only  to  the  slighter  cases 
that  we  wish  to  refer. 

The  symptom  which  prominently  characterizes  cerebral 
hyperaemia  is  sleeplessness,  or  sleep  disturbed  by  dreams  of  a 
vivid  and  distressing  kind.  Tubercular  meningitis  is  so  fre- 
quently preceded  by  dreams  of  this  latter  description,  that 
when  they  occur  persistently  in  children  they  should  be  re- 
garded with  suspicion  as  precursors  of  that  disease.  Cerebral 
hypereemia  is  usually  accompanied  by  headache,  flushed  face, 
throbbing  vessels,  giddiness  increased  by  stooping,  an  altered 
mental  condition,  irritability,  restlessness,  and  defective  mem- 
ory; and  in  children  by  convulsions.  The  pupils  are  usually 
contracted,  the  vision  is  impaired,  with  flashes  of  light  from 
the  eyes,  and  motes  floating  before  them;  there  are  noises  in 
the  ears,  and  other  abnormal  sensations  are  felt,  depending 
upon  perversions  in  the  sensory  centres  and  nerves.  The 
pulse  is  hard  and  frequent,  although  it  is  sometimes  slow. 
The  gastro-intestinal  functions  are  deranged,  and  these  de- 
rangements not  infrequently  aggravate  the  other  symptoms. 
In  the  cases  which  depend  upon  overwork,  such  as  have  al- 
ready been  discussed,  the  aspect  maybe  altered;  it  maybe 


128  Insomnia  and  its  Therapeutics. 

pale  and  haggard,  and  differing  very  decidedly  from  the  florid 
countenance  just  described,  being  suggestive  of  anaemia  rather 
than  of  hypereemia.  In  such  eases  the  pulse  must  be  used  as 
a  guide,  for  it  is  invariably  hard  and  incompressible. 

It  may  be  here  noted  that  the  difficulties  in  diagnosis  be- 
tween anaemia  and  hyperaamia  of  the  brain  are  much  greater 
than  might  be  supposed,  for  the  reason  that  many  of  the 
symptoms  which  characterize  the  one  may  be  said  to  charac- 
terize the  other.  These  opposite  conditions  lead  to  mal-nutri- 
tion  of  the  cerebral  cells,  and  these  cells  display  symptoms  of 
their  starvation,  which  are  alike  in  both  states.  Reference 
will  be  made  presently  to  the  resemblance  which  exists  be- 
tween acute  cerebral  anaemia  in  children,  and  hydrocephalus. 
The  ophthalmoscope  and  sphygmograph  give  little  or  no  help 
in  the  diagnosis.  It  is  only  by  carefully  considering  all  the 
facts  that  a  correct  conclusion  can  be  arrived  at.  Plethora  in 
the  one  case  and  anaemia  in  the  other  may  be  leading  features; 
though  some  of  the  cases  of  sleeplessness  which  occur  in  con- 
valescence from  severe  disease,  in  reality  owe  their  origin  to 
hypostatic  congestion  due  to  the  lying  posture,  rather  than  to 
the  anaemia  from  which  they  are  suffering,  a  fact  not  to  be 
lost  sight  of  in  the  treatment  of  these  cases. 

Treatment. — Whatever  be  the  cause  of  the  cerebral  con- 
gestion, the  treatment  must,  to  a  greater  or  less  extent,  be 
conducted  upon  antiphlogistic  principles.  The  patient  must 
rest  in  bed  with  a  well-raised  pillow  to  keep  the  head  high, 
with  light  and  warm  bedclothes;  in  a  darkened,  quiet,  cool, 
and  well-ventilated  room.  The  food  should  be  fluid  and  non- 
stimulating.  Moderate  depletion,  by  leeches  behind  the  ears, 
or  by  dry  or  wet  cupping,  is,  in  most  cases,  the  best  means  for 
insuring  speedy  relief,  and  that,  in  the  pale  and  haggard- 
looking  patients  we  have  just  referred  to.  The  trifling  loss 
of  blood  is  quickly  made  up,  and  the  immediate  effects  are  of 
the  happiest  kind;  it  may,  however,  require  to  be  repeated 
upon  two,  three,  or  more  occasions. 

In  the  slighter  cases  the  application  of  cold  to  the  head, 
by  means  of  ice-bags  or  Leiter's  tubes,  or  evaporating  lotions, 
is  generally  all  that  is  required;  particularly  if  it  is  used  coin- 
cidently  with  derivatives,  such  as  hot  sponging  to  the  spine; 
mustard  over  the  lower  limbs  or  epigastric  region;  or  the 
mustard  foot-bath. 


Insomnia  and  its   Therapeutics,  129 

Free  purgation  by  means  of  calomel,  jalap,  and  scammony 
is  called  for. 

$  Subchlor.  hydrarg., gr.  ij. 

Res.  scammon., gr.  ij. 

Pulv.  jalap,  co., .  3  i. 

F.  pulv.  i.     Sig.  Take  at  bedtime. 

The  following  may  be  prescribed  at  the  same  time : 

$  lod.  potass.,  .        .        .        .  •  .        .    3  i. 

Bromid.  potass.,    .        ...        ;        .     3  iv. 

Tinct.  aconit.  (B.  P.),    .        .        .  Tf[  xxxvi. 

Spt.  ammon.  arom.,      .        .        .        .        .3  iij. 

Aquam, .      ad  f  vi. 

M.     Sig.  Take  a  tablespoonful  in  water  every  four  hours. 

When  the  heart's  action  is  not  powerful,  3  ij.  of  chloral 
hydrate  may  be  substituted  for  the  aconite.  In  very  slight 
cases  a  saline,  such  as  a  teaspoonful  of  Carlsbad  salts  in  half 
a  teacupful  of  warm  chamomile  tea  at  bedtime,  acts  as  an 
excellent  hypnotic.  It  may  be  given  also  in  the  morning.  In 
convalescence,  electricity  and  the  use  of  sitz  baths  are  useful 
remedies. 

When  cerebral  congestion  arises  in  children  as  the  result 
of  teething,  sleeplessness  is  a  most  troublesome  symptom. 
The  swollen  and  tense  gums  should  be  thoroughly  incised; 
the  head  kept  cool  by  means  of  cold  applications;  warm  or 
tepid  baths  frequently  repeated ;  and  the  bowels  relieved  by 
gentle  laxatives.  Bromide  of  potassium,  monobromide  of 
camphor,  or  chloral  Ir^drate  may  be  given  every  three  or  four 
hours. 

Passive  Congestion  of  the  Brain. — The  symptoms  of  this 
affection  closely  resemble  those  of  the  active  variety;  indeed, 
the  most  marked  difference  that  exists  is  in  the  symptom 
under  consideration.  Wakef  ulness  is  not  nearly  such  a  prom- 
inent or  constant  feature  as  disturbed  sleep,  though  that  is 
keenly  felt  and  badly  borne.  When  the  patient  gets  off  to 
sleep  he  is  disturbed  by  frightful  dreams,  from  which  he 
awakes  in  terror — probably  a  more  distressing  condition  than 
lying  awake.  This  is  due  to  the  anaemia  with  which  it  is  in- 
variably associated,  for  the  blood  in  the  veins  is  useless  for 
the  purposes  of  nourishment. 


130  Insomnia  and  its  Therapeutics. 

Treatment. — The  remarks  on  regimen  in  the  last  para- 
graph may  be  held  as  applicable  here.  It  is  necessary  to  raise 
the  head  on  a  high  pillow  to  favor  the  return  of  blood  to  the 
heart.  Any  exciting  cause,  such  as  cough,  must  be  specially 
treated,  at  the  same  time  that  every  effort  is  made  to  improve 
the  tone  of  the  circulatory  system. 

Tonics,  diuretics,  and  mild  purgatives  are  called  for. 

$  Ext.  ergotae  liq., 3  iij. 

Tinct.  digital., 3  ij. 

Liq.  strychn., 3  i. 

Aquam  chloroform.,        .        .        .  ad  §  vi. 

M.    Sig.  Take  a  tablespoonful  in  water  three  times  a  day. 

Here,  as  in  most  anaemic  conditions  of  the  brain,  morphine 
is  admissible,  and  may  be  used  hypodermically  in  doses  of  -fa 
to  £  of  a  grain;  although  remedies  which  are  less  prone  to 
disorder  the  secretions  may  be  tried  first;  these  are  paralde- 
hyde,  ure  thane,  etc. 

Bartholow  recommends  galvanization  of  the  head  in  pas- 
sive cerebral  congestion. 

Cerebral  Anosmia. — The  diseases  which  give  rise  to  this 
affection  were  enumerated  in  Chapter  II. 

The  symptoms  vary  very  considerably  with  the  extent  of 
the  cause  and  the  degree  of  anaemia  it  induces. 

In  acute  cases  the  symptoms  are  rapidly  and  severely  de- 
veloped ;  in  chronic  cases,  although  existing  in  a  marked  de- 
gree, they  are  less  keenly  felt,  and  so  are  better  borne.  The 
symptoms  may  range  from  a  succession  of  violent  convulsions, 
the  result  of  a  profound  and  sudden  loss  of  blood,  to  a  passing 
feeling  of  faintness  depending  upon  sharp  pain.  When  it  is 
suddenly  produced  the  effects  are  chiefly  felt  by  the  special 
senses,  and  by  the  great  centres  in  the  medulla  oblongata, 
just  as  in  Flemming's  experiments  on  the  compression  of  the 
carotids,  in  which  unconsciousness  was  mistaken  for  sleep. 
The  patients  complain  of  dimness  of  vision,  noises  in  the  ears, 
vomiting,  sweating,  rapid  pulse,  sighing  respirations,  etc.,  in- 
dicating the  prostration  of  these  several  centres,  while  in- 
somnia is  always  an  urgent  source  of  distress. 

In  chronic  cases — and  it  is  with  these  that  we  are  more 
immediately  concerned — sleeplessness,  or  sleep  disturbed  by 


Insomnia  and  its  Therapeutics.  /i^l 

dreams,  and  general  restlessness,  are  usually  prominent  symp- 
toms. They  present  a  striking  contrast  to  the  drowsiness  and 
languor  which  prevail  throughout  the  day,  when  the  patient's 
mental  condition  is  one  of  weariness  and  irritability,  and  his 
thoughts  and  memory  are  confused  and  defective.  The  other 
striking  features  are  briefly,  pallor  of  the  surface  of  the  body; 
coldness  of  the  extremities;  pinched  face;  throbbing  or  pul- 
sating noises  in  the  ears,  sometimes  resembling  the  noises  of 
the  seashell;  dimness  of  vision,  flashing  of  light  from  the  eyes, 
dilated  pupils;  intolerance  to  noise  and  light;  small  and  com- 
pressible pulse,  frequently  "  splashing,"  and  generally,  al- 
though not  constantly,  of  low  tension.  The  cardiac  sounds 
are  enfeebled,  with  bruits  in  the  veins  of  the  neck ;  respira- 
tions are  less  frequent  than  natural.  Digestion  is  slow,  and 
the  bowels  are  constipated. 

In  the  cerebral  anaemia  of  children,  so  closely  resembling 
the  early  stages  of  hydrocephalus,  which  occurs  in  cases  of 
severe  and  copious  diarrhoea,  the  patient  is  very  restless,  and 
usually  sleeps  little  if  at  all;  the  face  is  pale,  eyes  sunken, 
features  pinched,  the  fontanelles  depressed  below  the  level  of 
the  bones,  while  the  muscular  system  generally  is  relaxed  and 
flabby,  and  the  bodily  surface  pale  and  cool.  The  effects  of 
this  state  are  keenly  felt  by  the  nerves  and  the  nervous  cen- 
tres, which,  being  improperly  nourished,  show  it  in  their  ex- 
citability. The  psychical,  motor,  and  sensory  centres  each  in 
their  own  peculiar  way  exhibit  evidence  of  this,  and  discharge 
their  energy  under  unusually  slight  stimulations;  one  of  the 
commonest  indications  of  this  being  wakefulness  and  restless- 
ness. 

Treatment. — In  acute  cases,  raising  the  foot  of  the  bed  so 
as  to  lower  the  head,  with  the  hypodermic  injection  of  mor- 
phine, is  of  the  greatest  use.  Under  no  circumstances  can  the 
tonic  and  stimulating  properties  of  morphine  be  so  well  studied. 
The  hypodermic  injection  of  sulphuric  ether  and  strychnine 
may  also  be  resorted  to. 

In  chronic  cases  the  treatment  must  be  directed  to  the 
constitutional  state  ere  relief  can  be  obtained.  Careful  atten- 
tion to  hygienic  conditions  is  absolutely  necessary,  so  that  all 
undue  fatigue  be  avoided,  and  that  the  largest  amount  of 
oxygen  and  sunlight  be  secured  for  the  patient  by  day,  and 
the  greatest  freedom  from  external  disturbing  agencies  by 


132  Insomnia  and  its  Therapeutics. 

night.  The  digestive  powers  must  be  improved  up  to  the 
highest  possible  point,  and  the  food  should  be  nutritious,  and 
on  the  lines  of  that  suggested  for  neurasthenic  conditions 
(p.  590).  Alcohol,  in  the  form  of  red  wine,  BurgundjT  or  claret; 
or  malt  liquor,  as  ale  or  stout,  in  quantity  calculated  to  im- 
prove assimilation,  must  be  given.  Iron  in  one  or  other  of  its 
forms,  and  arsenic,  are  the  remedies  to  be  relied  on,  and  they 
are  best  combined  with  laxatives. 


arsen.,      .......    3  ss. 

Mist,  ferri  co.,          ......     §  x. 

Decoct,  aloe,  co.,      ......     3  ij. 

M.     Sig.  Take  two  tablespoonfuls  thrice  daily,  after  meals. 

The  tincture  of  the  muriate  of  iron  of  the  Edinburgh  Phar- 
macopoeia combined  with  sodium  or  magnesium  sulphate  acts 
well.  Blaud's  pills  and  arseniate  of  iron  are  likewise  suitable 
remedies. 

The  Sleeplessness  of  Convalescence.  —  This  practically 
depends  upon  the  same  cause,  i.e.,  cerebral-cell  starvation. 
Evidence  of  this  may  sometimes  be  obtained  in  the  exagger- 
ated reflexes  which  can  be  elicited,  e.g.,  in  patients  recovering 
from  fevers.  In  this  state  it  is  important  for  the  patient  to 
avoid  over-fatiguing  himself  by  too  much  talking,  or  by  sitting 
up  too  long,  etc.,  as  these  indiscretions  accelerate  the  pulse, 
and  they  may  raise  the  body  temperature,  thereby  prevent- 
ing sleep  ;  moreover,  care  must  be  taken  to  avoid  over-feeding. 
Alcohol  is  an  invaluable  tonic  and  hypnotic,  a  glassful  of 
champagne  at  bedtime  frequently  acting  like  a  narcotic. 
Light  food  combined  with  a  stimulant,  once  or  twice  during 
the  night,  is  the  best  form  of  sleeping  agent.  Digitalis,  strych- 
nine, and  quinine  in  small  doses  are  useful  (p.  595).  Sponging 
with  tepid  water  frequently  is  soothing,  while  gentle  frictions 
are  also  provocative  of  sleep.  Change  of  posture  relieves  any 
hypostatic  congestion  of  the  brain.  If  a  t^pnotic  is  called 
for,  morphine  in  small  doses  is  the  most  suitable. 

Degeneration  of  the  Cerebral  Arteries.  —  This  is  a  factor 
in  the  causation  of  cerebral  hemorrhage,  and  it  appears  to 
exercise  a  decided  influence  upon  the  nutrition  of  the  cortical 
substance  of  the  brain. 

The  symptoms  are,  displays  of  emotional  feeling  upon  the 


Insomnia  and  its   Therapeutics.  133 

most  trivial  excitement;  drowsiness  during1  the  day,  even  to 
the  extent  of  falling1  asleep  during"  meals,  and  often  prolonged 
sleep  at  night.  But  in  a  certain  proportion  of  cases  there  is 
troublesome  dreaming-,  if  not  pronounced  wakefulness  at  night. 
To  such  an  extent  is  this  true,  that  dreaming  in  advanced 
years  may  be  held  as  suggestive  of  pending  apoplexy.  Dreams 
are  the  source  of  great  annoyance.  A  physician  who  had  re- 
tired into  well-merited  private  life,  told  the  writer  that  the 
only  miserable  time  he  had  was  when  he  was  asleep  dream- 
ing; he  died  shortly  afterward  of  apoplexy.  This  is  no  un- 
common experience.  In  some  cases  wakefulness  is  a  marked 
feature;  the  arteries,  hard  and  resistent,  are  no  longer  capable 
of  responding  to  the  vaso-motor  constrictors,  so  that  when 
sleep  should  naturally  occur,  the  blood-supply  is  not  moder- 
ated, and  consequently  sleeplessness  results. 

Treatment. — The  sleeping  conditions  require  attention. 
The  bedroom  should  be  comfortably  heated,  and  the  bed  well 
warmed  before  lying  down,  to  avoid  any  chill,  which  by  re- 
pelling the  blood  from  the  peripherj1-  is  apt  to  aggravate  the 
evil  by  increasing  the  cerebral  hyperaemia.  The  feet  should  be 
warmed,  and  the  head  well  raised.  The  writer  has  frequently 
got  good  results  from  sponging  the  nape  of  the  neck  with  hot 
water,  and  from  the  application  of  mustard  plasters  for  a  few 
minutes  over  the  epigastric  region,  or  the  upper  part  of  the 
spine.  A  light  repast  with  a  little  stimulant  at  bedtime,  just 
enough  to  excite  some  vascular  determination  to  the  stomach, 
without  accelerating  the  heart's  action,  is  frequently,  sufficient 
to  deplete  the  cerebral  vessels.  The  sumbul  and  hop  mixture 
(p.  597),  or  henbane  and  camphor  (p.  611)  are  sometimes  use- 
ful, but  as  they  cannot  modify  the  pathological  conditions, 
the%r  must  be  used  with  caution.  The  bromides  and  chloral 
hydrate  are  best  avoided. 

It  seems  convenient  here,  in  connection  with  this  subject, 
to  add  a  few  remarks  upon  some  other  forms  of  insomnia  met 
with  in  the  aged.  We  have  already  laid  some  stress  upon  the 
increased  amount  of  sleep  they  require,  and  in  many  instances 
get.  A  good  sleeping-habit  has  probably  much  influence  over 
the  prolongation  of  life.  The  statistics  of  forty-four  centen- 
arians, collected  by  the  Collective  Investigation  Committee 
of  the  British  Medical  Association  (1886),  proved  that  thirty- 
four  were  good  sleepers,  five  were  bad,  and  seven  were  moder- 


134  Insomnia  and  its   TJicrapeutics. 

ate  sleepers.  Returns  made  in  twenty-nine  cases,  indicating 
the  number  of  hours  slept,  showed  that  the  average  was  eight 
and  a  half  hours;  three  slept  twelve  hours,  eight  slept  ten, 
one  slept  four,  and  two  slept  six  hours.  Upon  the  whole  these 
figures  show  a  fair  amount  of  repose. 

Dyspeptic  Derangement. — This  is  a  fruitful  source  of  sleep- 
lessness. Digestion  being  slowly  and  imperfectly  performed, 
the  patient  complains  of  weight  and  oppression  over  the  epi- 
gastric region,  flatulence  and  heartburn,  the  tongue  being 
usually  dry  and  the  appetite  feeble.  This  depends  upon  im- 
perfect innervation  of  the  processes,  which  leads  up  to  defec- 
tive nutrition  of  the  whole  system.  The  heart  growing  weak, 
and  propelling  a  smaller  quantity  of  blood  feebly,  the  nervous 
centres  become  still  further  impaired.  These  sufferers  are 
usually  drowsy  during  the  day ;  they  drop  off  to  sleep  in  their 
chair,  but  at  night  on  assuming  the  recumbent  posture  they 
wake  up  and  become  sleepless.  In  less  pronounced  cases  these 
symptoms  are  only  apparent  after  indiscretions  in  eating  and 
drinking,  which  embarrass  the  enfeebled  digestive  powers. 

Treatment. — This  consists  in  aiding  digestion  with  alcohol. 
It  is  best  given  with  meals  in  quantities  short  of  producing 
catarrh  of  the  stomach;  it  is  likewise  useful  at  bedtime  and 
during  the  night.  A  tablespoonful  of  whiskey  diluted  with 
water  or  milk,  taken  at  bedtime  with  a  biscuit,  grapes  or 
raisins,  and  repeated  if  necessary  during  the  night,  is  a  most 
useful  hypnotic.  About  four  or  five  A.M.,  when  the  circulation 
is  depressed,  it  has  no  rival.  An  elderly  lady,  upward  of 
eighty  years  of  age,  who  for  a  few  years  has  derived  great 
benefit  from  this  regimen,  practically  sleeping  quite  well,  re- 
turned to  bed  one  night,  having  eaten  her  biscuit  and,  as  she 
thought,  sipped  her  stimulant,  but  found  she  could  not  sleep. 
After  tossing  uneasily  for  some  time  she  resolved  to  exceed 
the  prescription  by  repeating  it;  when  she  rose  to  do  so  she 
discovered  she  had  forgotten  to  drink  her  quantum,  which  she 
then  took  and  was  soon  asleep,  showing  that  the  stimulant  is 
required  as  well  as  the  food.  A  cardiac  tonic  is  often  usefully 
combined  with  the  stimulant.  Here  is  a  prescription  for  a 
mixture  which  a  lady,  now  considerably  over  eighty  years  of 
age,  has  had  at  her  bedside  for  the  last  thirteen  years,  and 
she  has  generally  required  to  take  it  once  or  twice  during 
every  night. 


Insomnia  and  its   Therapeutics.  135 

$  Tinct.  valerian., 3  iv. 

Spt.  ammon.  arom.,         .        .      ••.-..      ..      .  3  ij. 

Spt.  chlorof.,    .  i        .        .        .  3iij. 

Tinct.  lavand.  co.,   .        .        .        .        .  ,  3  iij. 

Infus.  digital.,          .        .        .        .        .      ad  §  iv. 

M.  Sig.  Take  a  tablespoonf ul  in  water  every  four  hours 
when  required. 

The  use  of  bromides,  hydrate  of  chloral,  and  other  hyp- 
notics, is  inadmissible.  The  food  requires  to  be  skilfully 
arranged. 

Pruritus  senilis  is  a  distressing  source  of  sleeplessness  in 
the  aged,  and  requires  careful  management.  It  is  usually 
met  with  in  persons  above  sixty  years  of  age,  in  whom  the 
skin  is  suffering  from  the  effects  of  defective  nutrition.  Many 
of  these  afflicted  persons  are  gouty. 

It  assumes  many  forms,  and  is  influenced  by  various  cir- 
cumstances, such  as  alterations  of  temperature,  and  is  inva- 
riably aggravated  by  the  heat  of  the  bed.  It  prevents  sleep, 
while  the  scratching  still  further  increases  the  distress,  just 
as  the  wearing  of  flannel  does.  It  most  frequently  affects  the 
region  of  the  anus  and  genitals,  and  the  lower  limbs. 

Treatment. — The  first  aim  must  be  to  regulate  the  diet 
and  correct  digestive  derangements,  for  these  aggravate  the 
itching.  Indeed,  exacerbations  are  apt  to  be  caused  by  indis- 
cretions in  eating  and  drinking.  The  emunctories  should  be 
kept  active.  Mild  mercurials  and  the  mineral  acids  are  very 
suitable  remedies.  To  promote  the  action  of  the  skin  frequent 
washings  are  required.  Baths  containing  borax,  bran,  or  oat- 
meal are  soothing  and  grateful.  Tonics,  such  as  arsenic, 
strychnine,  and  quinine,  often  yield  good  results,  although 
arsenic  in  some  instances  appears  to  increase  the  distress.  In 
some  cases  cannabis  indica  administered  internally,  by  lessen- 
ing the  conductivity  of  the  sensory  nerves,  promotes  sleep  by 
relieving  the  itching.  Warm  baths  at  night  often  promote 
sleep.  The  use  of  lanolin  has  been  strongly  recommended, 
and  the  writer  has  found  it  useful  mixed  with  two  parts  of 
cerat.  galena;  and  also,  with  one  part  of  the  oleate  of  zinc 
and  two  of  pure  white  vaseline.  Boracic  acid  ointment  and 
lotion,  and  ointments  containing  tar,  huile  de  cade,  carbolic 
acid,  and  menthol  are  all  serviceable.  Menthol  and  carbolic 


136  Insomnia  and  its   Therapeutics. 

acid  from  their  odor  sometimes  prevent  sleep.  The  lotions 
and  ointments  should  be  used  warm,  as  cold  applications  are 
prone  to  initiate  wakefulness  in  the  aged  by  exciting-  cerebral 
hyperaemia. 

For  twenty  years  the  writer  has  obtained  good  results 
from  a  prescription  of  Dr.  Bowling,  of  Kentucky,  as  quoted  by 
Tanner:  "I  direct  that  the  affected  parts  be  sponged  for  a 
minute  or  so  with  good  apple  vinegar,  and  then  allowed  time 
to  dry.  After  this  they  are  to  be  smeared  over  with  citrine 
ointment  (unguentum  hydrargyri  nitratis).  The  applications 
are  to  be  made  twice  a  day.  The  cure  is  usually  effected  in  a 
week." 

Intro-cranial  Tumors. — Sleeplessness  occurs  in  the  major- 
ity of  these  cases  as  a  consequence  of  the  headache  from  which 
the  patient  commonly  suffers.  Headache  appears  early  in 
the  disease,  and  is  often  the  only  symptom  of  the  organic 
mischief;  it  usually  persists  night  and  day,  and  tends  to  grow 
worse  at  night.  It  may  be  excruciating  in  character,  and  ex- 
ceed in  severity  all  headaches  depending  upon  functional  dis- 
orders, or  even  inflammatory  diseases  of  the  brain  and  mem- 
branes. 

It  prevents  sleep,  or  interrupts  it  if  it  has  ensued;  and  this 
characteristic  is  always  suggestive  of  organic  disease. 

The  sleeplessness  itself  becomes  a  source  of  aggravation, 
intensifying  the  suffering,  and  increasing  the  mental  and 
physical  exhaustion, 

Treatment. — From  the  fact  that  the  pain  is  increased  by 
any  active  or  passive  congestion  of  the  brain,  such  as  is  caused 
by  visual  and  auditory  stimuli,  coughing,  stooping,  etc.,  the 
head  should  be  well  raised  on  a  high  pillow,  in  a  darkened, 
quiet,  and  cool  room;  and  the  food  should  be  light  and  non- 
stimulating.  Cold  sometimes  relieves  pain:  ice-bags  and 
Leiter's  tubes  are  convenient  modes  of  applying  it.  If  it  is 
disagreeable  to  the  patient,  tepid  lotions  may  be  applied. 
Purgation,  by  relieving  the  hyperaemia,  is  useful.  The  follow- 
ing has  rendered  good  service : 

$  lodid.  potass., 3  ij.-  3  iv. 

Brom.  potass.,  .        .        ...        .  3  iv. 

Aq.  menth.  pip., ad  §  vi. 

M.     Sig.  Take  a  tablespoonful  every  four  hours  in  water. 


Insomnia  and  its  Therapeutics.  137 

When  there  is  much  arterial  tension,  TTUj.-TTUij.  of  tincture 
of  aconite  B.P.  may  be  added  to  each  dose. 

When  a  hypnotic  is  required  to  induce  sleep,  morphine  is 
the  only  reliable  remedy,  chloral  hydrate  having  no  influence 
over  pain.  Morphine  should  be  used  in  as  small  doses  as  is 
compatible  with  the  end  in  view.  It  must  not  be  forgotten 
that  coma  is  apt,  in  such  cases,  to  supervene  spontaneously. 

Cannabis  indica  has  been  strongly  recommended. 

When  the  diagnosis  of  such  tumors  is  clearly  made  out, 
they  pass  into  the  domain  of  the  surgeon. 

INSOMNIA  DEPENDING  UPON  AFFECTIONS  OF  THE  SPINAL. 
CORD,  NERVES,  ETC.  . 

Insomnia  in  diseases  of  the  spinal  cord  and  nerves  is 
chiefly,  if  not  altogether,  due  to  pain,  which  may  be  persist- 
ently present,  or  excited  by  muscular  movements.  It  is  pro- 
posed to  refer  briefly  to  one  or  two  of  these  affections. 

Spinal  Meningitis. — Sleep  is  speedily  interfered  with  by 
the  constitutional  disturbance  which  attends  the  onset  of  this 
malady.  There  are  also  present  excessive  pain  in  the  back, 
which  shoots  down  the  limbs,  and  is  greatly  increased  by  all 
voluntary  movements,  and  considerably  intensified  by  pres- 
sure; muscular  rigidity  and  spasm,  associated  with  frequent 
startings;  Ir^peraesthesia  in  the  early  stages,  with  formication 
and  tingling;  and  if  it  extends  to  the  cerebral  meninges,  head- 
ache and  vertigo.  The  reflexes  in  the  beginning  are  exagger- 
ated ;  while  paralysis,  usually  preceding  loss  of  sensation,  af- 
fects the  rectum  and  bladder,  and  may,  by  atrophic  changes, 
give  rise  to  bed-sores. 

In  consequence  of  these  disturbing  agencies  sleep  is  gen- 
erally very  broken,  and  when  it  ensues  it  is  dream-laden,  or 
disturbed  by  sleep-talking,  and  is  apt  to  be  rudety  terminated 
by  an  exacerbation  of  pain  excited  by  involuntary  muscular 
movements. 

Treatment. — The  early  recognition  of  the  disease  is  of  vast 
importance,  as  there  is  a  risk  of  its  being  mistaken  in  the 
earlier  stages  for  rheumatism,  with  which  disease  it  is  occa- 
sionally associated.  The  greatest  care  must  be  taken  to  avoid 
bed-sores  by  keeping  the  bed  scrupulously  clean  and  smooth; 
the  bowels  and  bladder  being  duly  watched.  Cupping,  dry 


138  Insomnia  and  its   Therapeutics. 

and  wet,  along1  the  whole  course  of  the  spine,  frequently  re- 
peated, with  the  use  of  mercurial  purgatives,  is  invaluable. 
The  following-  mixture  has  been  found  useful. 

$  lod.  potass., 3  ij. 

Brom.  potass., 3  iv. 

Liq.  ergot,  ext.,         .        .        .        .        .        .     3  iv. 

Aq.  chlorof., •     .      ad  3  vi. 

M.     Sig.  Take  a  tablespoonful  in  water  every  four  hours. 

It  sometimes  induces  sleep;  when  it  fails  morphine  must 
be  resorted  to;  or  opium  combined  with  small  doses  of  tartar 
emetic. 

If  the  potassium  salt  induces  iodism,  one  of  three  courses 
may  be  adopted.  The  dose  may  be  increased;  or  3  ij.  of  tinc- 
ture of  belladonna  may  be  added  to  the  mixture;  or  the  medi- 
cine may  be  taken  diluted  with  a  large  quantity  of  water. 

Dr.  Ross  speaks  well  of  warm  baths  and  moist  packs  as 
soothing  and  conducive  to  sleep. 

Myelitis. — The  symptoms  of  this  disease  are  essentially  of 
the  same  character  as  those  of  meningitis — constitutional  dis- 
turbance, etc.,  and  sleeplessness.  The  insomnia  requires  the 
same  treatment. 

Locomotor  Ataxy. — Sleeplessness  is  not  infrequently  asso- 
ciated with  this  affection,  having  begun  during  the  course  of 
the  disease  which  originated  it,  such  as  severe  continued  fevers, 
etc.  It  may  continue  throughout  the  initial  stages  of  the 
secondary  affection,  and  be  perpetuated. 

When  the  disease  has  developed,  sleeplessness  usually  de- 
pends upon  the  severe  lightning-pains,  severe  and  enduring 
pain  in  the  back,  girdle  sensations,  gastric  crises,  formication, 
and  pronounced  general  restlessness,  impelling  the  patient  to 
change  his  position  frequently. 

Treatment. — It  must  be  that  of  the  disease.  Turkish  baths 
and  hydropathic  treatment  are  in  most  cases  beneficial,  par- 
ticularly if  conjoined  with  electrization.  Nitrate  of  silver  and 
iodide  of  potassium  are  reliable  remedies.  Recently  excellent 
results  have  been  obtained,  so  far  as  relief  from  pain  is  con- 
cerned, from  antipyrine  and  antifebrine,  the  former  in  doses  of 
15  grains,  frequently  repeated,  the  latter  in  doses  of  8  grains. 
These  remedies  promise  to  be  the  best  hypnotics  in  this  affec- 
tion. When  the  pains  are  violent,  as  during  gastric  crises, 


Insomnia  and  its   Therapeutics.  139 

morphine  must  be  given  freely.  The  writer  has  known  as 
much  as  20  grains  required  in  24  hours.  Suspension  seems,  in 
some  cases,  to  afford  good  results. 

Infantile  Paralysis. — Sleep  is  often  very  disturbed  at  the 
onset. 

Neuralgia. — Sleeplessness  is  often  caused  by  the  pain  that 
this  ailment  induces,  as  well  as  by  the  constitutional  state 
which  gives  rise  to  it.  It  is  chiefly  seen  in  the  debilitated,  or 
in  those  who  are  suffering  from  some  toxic  condition. 

Hence  it  is  met  with  in  the  anaemic  and  weakly,  and  in 
those  afflicted  by  gouty,  rheumatic,  sj^philitic,  or  malarial 
poisons.  The  disease  is  characterized  by  severe,  even  agoniz- 
ing, unilateral,  periodic,  and  paroxysmal  pain.  The  parox- 
ysms frequently  select  sleep  as  the  time  for  their  occurrence, 
and  they  are  usually  more  severe  during  the  night.  The  pain 
is  attended  by  tenderness  on  pressure  over  some  portion  of 
the  nerve;  and  occasionally  is  accompanied  by  swelling,  ery- 
thematous  or  herpetic  changes  in  the  skin  over  the  nerve. 

The  sensation  of  pain  being  transmitted  to  the  brain  keeps 
it  in  a  hyperaBmic  state,  which  is  incompatible  with  sleep,  at  the 
same  time  that  it  increases  the  force  of  the  heart's  action. 
Neuralgias  receive  different  names  as  they  affect  different 
cranial  nerves,  plexuses  of  spinal  nerves,  or  internal  organs  or 
viscera. 

Treatment. — It  is  divided  into  curative  and  palliative;  the 
latter  is  often  concerned  with  the  promotion  of  sleep. 

Antipyrine  and  antifebrine  are  distinct  gains  to  the  materia 
medica.  They  both  possess  the  power  of  relieving  pain,  espe- 
cially that  of  neuralgia,  without  disturbing  the  digestive  pro- 
cesses. The  dose  of  the  former  is  from  10  to  20  grains  thrice 
daily,  and  of  the  latter  from  5  to  15  grains. 

Morphine  and  cocaine  by  hypodermic  injection  are  the  relia- 
ble remedies  for  pain ;  the  dose  should  be  limited  to  that  which 
will  ameliorate  it.  Antipyrine  may  also  be  administered  hy- 
podermically,  either  alone  or  with  cocaine. 

Local  applications  of  menthol,  aconite,  veratria,  belladonna, 
chloroform,  opium,  heat,  blisters,  and  electricity  are  each  and 
all  useful.  Electricity  is  at  once  curative  and  an  aid  to  sleep. 

In  the  angemic  and  weakly,  special  attention  should  be  paid 
to  diet,  and  probably  wine  must  be  allowed.  Various  tonics, 
as  iron,  arsenic,  phosphorus,  and  quinine,  by  improving-  the 
general  health  and  by  relieving  pain,,  admit  of  sleep. 


140  Insomnia  and  its  Therapeutics. 

In  those  suffering1  from  gouty,  rheumatic,  syphilitic,  and 
malarial  poisons,  the  remedies  must  be  directed  against  these 
states. 

In  neuralgia  of  the  fifth  cranial  nerve,  gelsemium  with  hy- 
drobromic  acid  and  quinine;  or  the  butyl-chloral  hydrate  will 
probably  suit  best. 

In  brachialgia,  rest  for  the  limb,  antipyrine,  Warburg's 
tincture,  sal  ammoniac  with  belladonna,  and  nerve  stretching. 

In  herpes  zoster,  arsenic  and  quinine. 

In  lumbago,  dry  cupping,  acupuncture,  antipyrine,  and  sal 
ammoniac. 

In  sciatica,  fly  blisters,  dry  cupping,  acupuncture,  turpen- 
tine, potassium  iodide,  and  nerve  stretching. 

In  ovarian  neuralgia,  blisters  and  potassium  bromide  are 
the  remedies  which  have  afforded  the  writer  the  best  results. 

In  all  cases  the  emunctories  must  be  attended  to.  Much 
relief  is  occasionally  gained  by  the  judicious  administration  of 
a  purgative. 

Other  painful  affections,  such  as  biliary  or  renal  calculi, 
and  like  acute  ailments,  are  best  treated  with  morphine  in 
adequate  doses.  Neuromata  should  be  removed.  Cancers  and 
similar  chronic  painful  diseases  necessitate  the  continued  use 
of  morphine  or  cocaine ;  the  former  dusted  over  the  open  sore 
has  afforded  Dr.  Thomas  Keith  excellent  results.  Given  hy- 
podermically,  the  dose  should  be  kept  as  small  as  possible,  for 
unfortunately  a  time  arrives  when  it  no  longer  acts  as  a  seda- 
tive; on  the  contrary,  it  seems  to  act  as  an  irritant,  while  it 
demoralizes  the  whole  man.  Pure  hypnotics  have  no  influ- 
ence in  such  cases.  They  operate,  for  the  most  part,  directly 
on  the  cerebral  cells.  No  remedy  is  of  any  avail  in  painful 
affections  which  does  not  act  on  the  sensory-nerve  endings  and 
lessen  their  excitability  and  transmitting  functions.  Bella- 
donna, morphine,  aconite,  etc.,  possess  such  properties — hence 
their  usefulness.  Cocaine  injected  subcutaneously  relieves 
pain,  apparently  by  constricting  the  arterioles  and  so  render- 
ing the  nerve  terminals  bloodless. 

Irritants,  such  as  insects  or  pediculi;  itching,  from  urticaria 
and  like  affections;  blistered  surfaces,  etc.,  are  all  able  to  in- 
terfere with  sleep;  but  their  presence  being  recognized  and 
their  cure  effected,  sleep  will  return.  Temporarj'  relief  can  be 
obtained  and  sleep  induced  by  hyoscj^amus,  cannabis  indica, 
camphor,  etc. 


CHAPTER  VIII 

INSOMNIA  DEPENDING  UPON  AFFECTIONS  OF  THE 
NERVOUS  SYSTEM— Concluded. 

IT  is  proposed,  in  concluding1  these  chapters,  to  briefly  dis- 
cuss insomnia  depending1  upon  the  influence  of  certain  toxic 
agents  upon  the  economy. 

Alcoholism. — The  varying1  effects  of  alcohol  upon  sleep  and 
sleeplessness  are  due  to  the  susceptibility  of  the  person  who 
consumes  it,  to  the  quantity  and  quality  taken,  and  likewise 
to  the  intermingling  of  various  kinds  of  drinks. 

Persons  intolerant  of  alcohol,  or  unaccustomed  to  its  use, 
ma3T  be  rendered  sleepless  by  a  very  small  quantity,  probably 
by  its  exciting  the  action  of  the  heart  and  causing  cerebral 
hypersernia.  If  such  persons  suffer  from  insomnolency  from 
any  cause,  alcohol  invariably  aggravates  the  symptom. 

In  those  who  are  accustomed  to  its  strictly  moderate  use, 
a  small  dose  at  bedtime  acts  as  a  hypnotic,  probably  by  estab- 
lishing a  temporary  gastric  congestion  and  a  corresponding 
cerebral  anaemia.  Such  persons  only  realize  its  Iwpnotic  prop- 
erties when  they  tr3r  to  abandon  its  use.  They  then  experience 
for  some  nights  great  difficulty  in  falling  asleep,  greater  diffi- 
culty indeed  than  they  would  have  believed  possible. 

In  this  temperate  class,  a  larger  quantity  of  alcohol  pro- 
duces sleep  disturbance,  and  especially  when  the  spirits  or 
wines  are  impure  or  unsound,  or  when  they  are  injudiciously 
mixed.  The  quality  and  admixture  appear  to  exercise  as  great 
a  pernicious  influence  as  the  quantity. 

When  an  overdose  of  alcohol  is  taken  (and  that  is  a  relative 
quantity)  profound  or  drunken  sleep  follows,  in  which  the  pupils 
become  very  contracted.  If  such  a  person  is  disturbed  or 
aroused  the  pupils  dilate,  an  occurrence  that  has  been  made 
use  of  in  distinguishing  between  alcoholic  and  opium  poison- 
ing; for  in  the  latter  they  do  not  dilate.  While  the  utility  of 
this  means  of  diagnosis  is  very  great,  it  is  really  only  what 


142  Insomnia  and  its   TJicrapcutics. 

happens  in  deep  sleep,  and  is  in  no  respect  peculiar  to  alcoholic 
excess. 

The  majority  of  persons  who  habitually  consume  alcohol 
in  quantity  exceeding1  physiological  limits,  although  short  of 
inducing  delirium  tremens,  eventually  suffer  from  alcoholism. 
This  is  attended  by  well-marked  symptoms  during  life,  and 
by  structural  changes  in  the  brain  and  nervous  system  which 
can  be  studied  after  death.  To  the  latter  we  shall  refer  first. 

The  dura  mater  is  frequently  found  adherent  to  the  cranial 
bones,  the  arachnoid  devoid  of  its  normal  transparency,  the 
pia  mater  thickened,  the  convolutions,  particularly  those  of 
the  frontal  lobes,  shrunken  and  atrophied,  and  an  increased 
amount  of  fluid  in  the  ventricles  and  in  the  arachnoid  spaces. 
In  post-mortem  examinations  made  of  the  bodies  of  a  very 
large  number  of  persons  who  had  been  addicted  to  drinking 
the  writer  never  failed  to  note  these  atrophic  changes  in 
greater  or  less  degree.  Organic  changes  in  the  liver,  stomach, 
etc.,  were  equally  constant. 

During  life  the  patient  presents  symptoms  of  mental  en- 
feeblement,  in  which  the  intellectual,  emotional,  and  volitional 
centres  participate,  as  evidenced  by  incapacity,  irritability, 
and  vacillation;  eventually  he  becomes  demoralized,  deceitful, 
and  untruthful.  He  complains  of  headache,  depression  of 
spirits,  occasional  attacks  of  giddiness,  weakness  of  vision, 
scintillations,  muscce  volitantes,  and  impairment  of  hearing. 
He  is  restless,  his  muscles  tremble  and  twitch.  The  tremors 
are  worse  in  the  morning,  and  manifest  themselves  mostly  in 
the  Upper  limbs;  the  twitchings  are  most  marked  at  night 
when  he  tries  to  fall  asleep.  He  suffers  from  abnormal  sensa- 
tions of  heat  and  cold,  and  from  formication  in  the  limbs,  at 
times  from  severe  neuralgic  pains.  His  movements  are  often 
ataxic,  and  at  times  he  is  paratyzed  from  multiple  neuritis. 
He  is  the  subject  of  chronic  gastric  catarrh,  and  of  liver  de- 
rangements. Such  a  patient  comes  for  advice,  not  on  account 
of  his  general  condition,  but  for  sleeplessness  and  mental  de- 
pression, the  former  becoming-  very  marked  in  the  later  stages. 
Sleep  is  either  absent  or  disturbed  by  frightful  dreams,  night- 
mare, and  general  restlessness.  It  is  the  reverse  of  refreshing, 
and  the  patient  gets  up  in  the  morning  feeling  miserable,  and 
full  of  dread  and  dismay.  Sleeplessness  depends  conjointly 
upon  the  noxious  effects  of  the  poison  on  the  cerebral  cells, 


Insomnia  and  its   Therapeutics.  143 

hyperaemia  of  the  brain,  the  vaso-motor  paresis  which  follows, 
and  the  accompanying  digestive  troubles. 

In  cases  less  pronounced,  such  as  are  induced  by  alcohol 
only  slightly  in  excess  of  physiological  limits,  sleep  may  be 
deep  and  heavy  in  the  early  part  of  the  night,  but  it  terminates 
about  four  or  five  o'clock,  and  does  not  return  till  nearly  the 
hour  for  rising.  A  history  of  wakefulness  occurring  at  that 
hour,  and  accompanied  with  restlessness,  should  always  sug- 
gest, at  least,  the  possibility  of  its  being  alcoholic. 

Treatment. — All  stimulant  must  at  once  be  withdrawn 
from  those  who  can  bear  its  withdrawal,  and  materially  re- 
duced in  the  case  of  those  who  are  enfeebled.  The  food  must 
be  carefully  arranged.  The  first  indication  is  to  unload  the 
liver  and  restore  the  digestive  powers.  This  may  be  accom- 
plished by  means  of  a  calomel  purge,  followed  in  the  morn- 
ing by  a  dose  of  one  of  the  natural  saline  waters,  and  an  alka- 
line mixture  before  meals. 

I£  Bicarb,  potass.,       .        .  ...  3  iij. 

Tinct.  nucis  vom.,  .        .        .        .  .  3  ij. 

Liq.  arsen.  sodii, .  3  ss. 

Tinct.  capsic.,  .        .        .        .        .        .  3  ss. 

Infus.  cascaril., ad  f  vi. 

M.  Sig.  Take  a  tablespoonful  in  water  thrice  daily  before 
meals. 

The  nux  vomica  by  influencing  the  vaso-motor  centres 
acts  in  many  cases  as  a  hypnotic.  Warm  applications,  as  a 
mustard  plaster  or  a  compress  over  the  stomach  and  liver, 
are  useful  adjuncts  to  treatment.  For  some  nights  it  is  neces- 
sary to  administer  a  hypnotic  to  insure  sleep.  There  are 
many  which  act  admirably;  probably  the  best  are  hydrobro- 
mate  of  hyoscine,  chloral  hydrate,  paraldehyde  and  sulphonal; 
but  the  monobromide  of  camphor  and  amylene  hydrate  are 
also  suitable.  Antipyrine  relieves  headache,  nausea,  and  the 
sense  of  sinking,  and  occasionally  promotes  sleep. 

During  convalescence,  electricity,  change  of  air  and  scene, 
sea-bathing,  and  a  mixture  of  strychnine  and  quinine  with 
dilute  nitro-muriatic  acid,  are  the  best  remedies  to  establish 
health  and  restore  sleep. 

The  Morphine  Habit.— Morphine  taken  for  any  length  of 


144;  Insomnia  and  its  Therapeutics, 

time  leads  to  sleep  disturbance,  while  its  discontinuance  is  fol- 
lowed by  pronounced  insomnia. 

Disturbed  sleep  from  this  cause  is  difficult  to  diagnose,  for 
the  reasons  that,  in  the  earty  stages  of  mild  cases,  the  objec- 
tive symptoms  are  less  marked  than  those  in  the  case  of  alco- 
hol, and  that  there  is  usually  a  strong  desire  on  the  part  of 
the  patient  to  conceal  the  fact  that  he  is  addicted  to  the  use 
of  narcotics;  indeed,  he  may  be  striving  to  abandon  the  habit. 
In  the  later  stages,  and  in  pronounced  instances,  this  difficulty 
disappears. 

The  practice  of  taking  morphine  by  the  mouth  or  hypo- 
dermically  has  increased  rapidly  of  late  years,  and  has  largely 
displaced  the  consumption  of  opium  in  the  solid  and  liquid 
forms.  Many  of  the  persons  addicted  to  it  are  quite  above  the 
suspicion  of  such  a  habit,  and  discharge  high  and  important 
duties  with  ease  and  eclat. 

The  quantity  taken  may  range  from  half  a  grain  to  twenty 
or  more  grains  in  the  course  of  twenty-four  hours. 

Such  patients  complain  that  their  nights  are  wakeful, 
though  quiet;  or  if  sleep  does  come  on  it  is  disturbed  by 
dreams,  and  in  the  morning  they  awake  unre freshed,  miser- 
able, and  dispirited.  After  a  time,  longer  or  shorter,  depend- 
ing upon  the  strength  of  the  patient  and  the  quantity  taken, 
morphine  produces  well-marked  modifications  in  the  nervous 
S3rstem  generally.  The  intellect  is  enfeebled;  the  emotional 
centres  display  their  weakness  in  increasing  excitability,  and 
the  volitional  in  demoralization;  the  control  of  the  will  is  in 
abeyance;  the  disposition  is  changed;  men  deeply  religious 
and  scrupulously  punctilious  grow  deceitful  and  untruthful. 
They  suffer  from  severe  neuralgic  pains  in  the  limbs;  from 
hyperaesthesia  or  anaesthesia;  from  muscular  twitchings  and 
tremblings,  the  twitchings  being  more  marked  during  the 
night  when  they  are  at  rest  in  bed;  and  from  perversion  of 
the  special  senses  and  defective  vision.  The  eyes  are  dull  and 
expressionless,  the  pupils  generally  contracted,  but  not  alwaj-s 
so.  They  suffer  from  the  effects  of  enfeeblement  of  the  vaso- 
motor  centres,  as  well  as  of  the  centres  which  control  the  car- 
diac, respiratory,  and  digestive  functions,  etc.  Itching  of  the 
skin  is  occasionally  very  troublesome. 

Treatment.— This  obviously  consists  in  breaking  off  the 
habit,  which  in  all  cases  is  extremely  difficult.  The  persistent 


Insomnia  and  its   Therapeutics.  145 

insomnia  which  accompanies  the  attempt,  lasting  through 
days  and  nights,  may  endanger  life.  Much  difference  exists 
in  the  ability  of  persons  to  abandon  the  habit.  In  a  recent 
case  in  which  insomnia,  neuralgic  pains  in  the  limbs,  general 
emaciation,  etc.,  were  clearly  due  to  morphine  that  had  been 
taken  for  some  3rears  subsequent  to  a  painful  illness,  the  pa- 
tient abandoned  it  from  the  moment  he  was  advised  to  do  so; 
but  the  struggle  was  such  that  he  said,  if  he  ever  again  ac- 
quired the  habit,  he  would  not  attempt  to  give  it  up.  Such 
an  experience  is  by  no  means  uncommon,  though  it  is  not  the 
usual  one.  The  habit  appears  to  be  more  easily  relinquished 
if  the  drug  has  been  used  for  the  relief  of  pain,  especially  if 
the  pain  abates. 

Many  patients,  who  during  days  and  weeks  have  taken 
enormous  doses  of  morphine  for  pain,  are  able  to  abandon  the 
practice  easily  and  quickly.  The  writer  has  known  a  patient 
do  this,  who  had  taken  for  some  time  as  much  as  seventeen 
grains  every  twenty-four  hours.  A  good  deal  depends  upon 
their  temperament. 

Where  the  patient  can  at  once  and  forever  give  it  up  he 
should  do  so.  Dr.  B.  W.  Richardson,  who  has  given  the  sub- 
ject much  careful  consideration  based  upon  the  observation  of 
a  large  number  of  cases,  thinks  that  in  aggravated  instances 
a  gradual  plan  is  to  be  preferred  ("Asclepiad,"  1884).  With 
this  the  writer  is  in  accord.  The  trial  necessitates  the  isola- 
tion of  the  patient,  and  the  services  of  two  trustworthy  nurses, 
and  careful  feeding.  Ammonia  and  wine  must  be  adminis- 
tered when  there  are  symptoms  of  great  weakness.  As  soon 
as  possible  strychnine  and  arsenic  should  be  given. 

5  Liq.  arsen.  hydrochl., 3  ss. 

Liq.  strychnin., 3  i. 

Tinct.  quinin., 3  xivss. 

M.  Sig.  Take  a  teaspoonful  in  water  before  meals  thrice 
daily. 

Since  the  introduction  of  sulphonal,  the  writer  has  had  one 
such  case  under  his  care,  and  his  experience  of  this  remedy 
was  so  satisfactory  that  in  future  he  will  give  it  an  extended 
trial.  Change  of  air  and  scene  are  generally  required  in  the 
convalescing  stage. 

The  Chloral  Habit. — Chloral  hydrate  taken  for  any  length 


146  Insomnia  and  its   Therapeutics. 

of  time,  even  in  strictly  medicinal  doses,  is  apt,  like  opium  and 
morphine,  to  create  a  habit,  particularly  in  those  possessing-  a 
neurotic  temperament. 

It  is  in  many  respects  a  more  dangerous  medicine  than 
morphine.  At  first  the  mental  depression  and  melancholia 
from  which  the  patient  suffers  are  alleviated  by  a  dose  of  the 
drug1;  after  a  time  it  fails  to  soothe,  and  it  may  even  excite. 
The  victim  gravitates  into  a  pitiable  state  of  mental  weakness 
and  demoralization,  becoming-  childish,  vacillating-,  and  un- 
truthful; sometimes  dejected,  at  other  times  excited,  and 
having  suicidal  tendencies.  The  symptoms  are  due  to  cere- 
bral anasmia  and  enervation  of  the  heart,  lungs,  etc. 

The  large  number  of  deaths  which  have  followed  the  use  of 
this  drug  points  to  the  care  with  which  it  should  be  prescribed. 
The  sleeplessness  of  the  chloral  habit  is  the  symptom  which 
calls  for  the  most  urgent  consideration  in  the  attempt  to 
break  that  habit. 

Treatment. — This  consists  in  isolating  the  patient,  so  as  to 
render  it  impossible  for  him  to  get  or  take  the  drug  surrepti- 
tiously. He  must  be  fed  with  light  and  nutritious  food  at 
short  intervals,  and  stimulated  with  diffusible  agents,  such  as 
ammonia  and  camphor.  In  convalescence,  citrate  of  caffeine 
acts  most  beneficially,  while  change  of  the  physiological  con- 
ditions of  life  does  much  to  complete  the  cure.  Supervision, 
however,  is  necessary  for  several  months.  Strychnine  is  like- 
wise serviceable  in  combination  with  tincture  of  hydrastis. 

Cocaine  Habit. — The  .  administration  of  cocaine  appears 
to  be  accompanied  by  a  risk  of  forming  a  habit  which  is  at- 
tended by  sleeplessness.  Several  such  cases  have  come  under 
observation.  Of  the  poisonous  qualities  of  the  drug  there  is 
abundant  evidence. 

In  December  last,  the  writer  saw  in  consultation  a  case  of 
chronic  cocaine-poisoning,  complicated  by  small  doses  of  chloral 
hyd  rate ;  but  the  symptoms  of  the  former  poison  predominated. 
It  was  characterized  by  great  excitement,  hallucinations  chiefly 
connected  with  sight  and  hearing,  and  associated  with  ani- 
mals. The  patient  believed  her  skin  was  full  of  small  insects, 
and  that  her  room  was  infested  by  serpents  and  other  reptiles. 
The  lower  limbs  were  so  enfeebled  that  she  was  almost  para- 
plegic; while  her  sleeplessness  was  of  the  most  pronounced 
kind.  She  was  isolated,  well  and  carefully  nursed,  and  fed 


Insomnia  and  its   TJicrapeutics.    '  147 

with  suitable  food.  She  took  with  the  greatest  benefit  gr.  20 
of  sulphonal  for  several  nights;  and  during  her  convalescence, 
which  was  rapid,  a  mixture  containing  nux  vomica. 

In  February,  1889,  after  an  operation  for  hemorrhoids,  she 
became  afflicted  with  pain  at  the  entrance  to  the  vagina,  for 
which  her  attendant  prescribed  a  22-per-cent  ointment  of 
cocaine,  and  being  ignorant  of  its  nature  she  used  it  freely. 
Speedily  she  began  to  develop  peculiar  symptoms,  which  in- 
creased, until  the  former  symptoms  of  sleeplessness,  hallucina- 
tions, and  paresis  of  the  limbs  were  all  markedly  present:  the 
knee-jerk  was  greatly  lessened  if  not  alogether  absent.  Their 
import  was  recognized,  and  traced  to  their  true  origin.  The 
remedy  was  abandoned,  and  she  steadily  recovered. 

Tea  and  Coffee. — These  pleasant,  refreshing,  and  sustain- 
ing beverages  are  used  almost  universally  in  the  morning  at 
breakfast  to  dispel  any  traces  of  sleep.  It  has  been  astutely 
remarked  that  we  drink  alcohol  at  night  to  woo,  and  tea  hi 
the  morning  to  drive  away,  sleep.  Tea  and  coffee  have  a  very 
decided  effect  upon  the  nervous  system.  In  strictly  moderate 
quantity  they  promote  mental  activity,  which  is  evidenced  by 
an  accelerated  rapidity  of  thought  and  clearness  of  judgment; 
and  they  strengthen  and  invigorate  the  body.  They  are 
largety  used  by  the  wearied  and  jaded  on  account  of  the  men- 
tal exhilaration  they  induce — an  animation  which  is  not  fol- 
lowed lay  depression.  They  are  employed  to  relieve  many 
forms  of  headache;  and  so  positive  are  their  anti-hypnotic 
properties  that  they  are  used  (by  those  who  wish  to  continue 
their  labors  into  the  night)  to  prevent  sleep.  For  a  like  rea- 
son they  are  called  into  requisition  in  narcotic  poisoning;  and 
they  have  been  prescribed  in  many  febrile  and  inflammatory 
diseases  to  dispel  slight  stupor. 

Tea  and  coffee  have  been  credited  with  the  power  of  acting 
upon  different  regions  of  the  cerebrum,  and  so  producing  vary- 
ing effects.  They  certainly  act  somewhat  differently  on  the 
economy;  coffee  being  less  stimulating  and  restorative  than 
tea,  and  thus  less  productive  of  wakefulness;  but  it  is  more 
prone  to  derange  the  biliary  organs. 

They  each  contain  several  similar  principles.  Three  of 
these  may  be  named :  a  volatile  oil ;  alkaloids,  theine  and  caf- 
feine; tannin  and  caffeo-tannic  acid. 

A  Volatile  Oil. — It  is  this  that  imparts  the  characteristic 


148  Insomnia  and  its   Therapeutics. 

aromatic  taste  and  odor  to  tea  and  coffee.  According1  to  the 
analysis  of  Mulder,  black  tea  contains  0.60  and  green  tea  0.79 
per  cent.  This  is  one  of  the  constituents  of  tea  and  coffee  that 
influence  the  brain  and.  nervous  system.  Taken  in  excess  it 
causes  a  train  of  nervous  symptoms,  among-  the  most  marked 
of  which  are  tremors  and  sleeplessness.  On  account  of  the 
larger  quantity  that  green  tea  contains,  it  is  usually  selected 
as  a  remedy  in  cases  of  opium-poisoning.  As  the  oil  is  im- 
bedded in  the  cellular  tissue  of  the  leaf,  it  is  evident  that  time 
is  required  for  its  complete  extraction.  This  explains,  to  a 
certain  extent,  why  tea  infused  for  a  long-  time  is  more  apt  to 
render  persons  wakeful.  When  the  oil  has  been  extracted  (being- 
volatile)  it  is  easily  driven  off  by  boiling,  and  even  by  exposure 
to  the  air.  Mr.  John  Borland,  F.C.S.,  of  Kilmarnock,  has  sug- 
gested that  the  oil  enters  into  combination  with  the  theine 
and  forms  a  compound  which  is  more  soluble  than  the  tannate, 
and  consequently  is  absorbed  more  quickly  in  the  stomach.  He 
bases  this  opinion  on  the  fact  that  theine  is  readily  soluble  in 
several  volatile  oils  at  180°  Fahr.,  while  it  is  only  soluble  in 
75  parts  of  cold  and  in  9^  of  boiling1  water.  He  has  suggested 
also  that  an  infusion  of  tea  containing  milk  and  cream  favors 
this  combination,  as  the  tannic  acid  precipitates  the  casein 
of  the  milk  and  allows  the  theine  to  unite  the  volatile  oil.  He 
argues  from  this  that  an  infusion  of  tea  containing  milk  or 
cream  should  stimulate  more  quickly  than  one  without  these 
additions.  The  writer  has  met  with  no  facts  to  bear  this  out 
so  far  as  tea  is  concerned.  He  has,  however,  been  often  told 
by  patients  that  they  could  drink  cafe  noir  after  dinner  and 
sleep  soundly,  while  cafe  au  lait  rendered  them  wakeful. 

Alkaloids. — Theine  and  caffeine.  These  are  obtained  from 
tea  and  coffee  respectively.  They  appear  to  resemble  each 
other  very  closely,  if,  indeed,  they  are  not  essentially  the  same 
substances.  It  has,  however,  been  pointed  out  by  Mays  that 
theine  injected  hypodermically  possesses  certain  local  anaes- 
thetic properties,  and  that  it  interferes  with  sensation  in  frogs; 
effects  that  are  not  caused  by  caffeine. 

Theine  exists  in  green  and  black  teas  in  almost  identical 
quantities,  and  in  amount  considerably  exceeding  that  found 
in  coffee.  It  appears  to  be  a  tolerably  constant  or  equable 
constituent  of  tea.  Paul  and  Cownley,  who  analyzed  twenty 
samples  of  Indian  and  Ceylon  teas  differing-  widely  in  price, 


Insomnia  and  its  Therapeutics,  149 

reported  that  the  theine  varied  from  4.66  per  cent  in  the  high- 
est class,  to  3.22  per  cent  in  the  lowest.  They  likewise  pointed 
out  that  an  ordinary  spoonful  of  tea  contains  about  sixty 
grains,  and  that  an  infusion  of  that  quantity  of  an  average  tea 
(4  per  cent)  yielded  in  five  minutes  over  half  of  the  two  and  a 
half  grains  it  contained,  about  one  to  one  and  a  quarter  grains 
of  theine.  (The  size  of  the  particles  of  tea  with  reference  to 
the  quantity  that  ordinary  spoons  are  capable  of  holding,  is  a 
point  of  some  importance.  Dr.  E.  Smith,  who  first  attracted 
attention  to  this  point,  formulated  a  table,  from  which  the 
following  items  are  extracted : 

irir.H  r.t  too  Weight  of  a  spoon-    Number  of  spoon- 

ful in  grains.  fuls  in  a  pound. 

Black: 

Oolong,        .        .        .        .        .39  179 

Congou,  inferior  quality,   .        .  52  138 

Flowery  Pekoe,  ....  62  113 

Souchong, 70  100 

Congou,  fine,       ....  87  80 

Green : 

Hyson, 66  106 

Fine  Imperial,    ....  90  77 

Scented  Caper,   ....  103  68 

Fine  Gunpowder,       ...  123  57 

Retailers  who  are  alive  to  the  fact  that  the  smaller  the  tea 
the  more  there  is  consumed,  try  to  supply  it  in  as  broken  a 
state  as  possible.  This  is  worth  bearing  in  recollection,  as 
teaspoonfuls  of  tea  may  be  very  different  quantities.) 

Theine  and  caffeine  exert  a  decided  influence  over  the 
medullary  centres,  increasing  the  force  of  the  heart,  and  at 
first  raising  the  blood-pressure.  They  also  act  as  diuretics. 
Tea  and  coffee  produce  much  more  marked  wakefulness  than 
the  quantity  of  theine  and  caffeine  they  contain  would  do  if 
taken  alone.  This  is  due  to  the  volatile  oil. 

Tea  contains  a  large  amount  of  tannin,  and  coffee  of  caffeo- 
tannic  acid.  The  former  impedes  in  a  very  decided  manner, 
and  the  latter  in  a  less  marked  way,  salivary  and  gastric 
digestion.  This  well  explains  the  dyspepsia  and  wakefulness 
which  follow  the  use  of  tea  after  dinner  in  certain  cases.  Tea, 
retarding  the  solution  and  digestion  of  starches  and  albumi- 
noids, is  obviously  the  reason  why  that  most  objectionable  of 


150  Insomnia  and  its   Therapeutics. 

all  meals,  "  high  tea,"  so  frequently  disturbs  sleep.  It  appears, 
however,  to  delay  the  digestion  of  some  nitrogenous  foods 
more  than  others,  as  it  does  not  retard  that  of  smoked,  dried, 
or  cured  fish  or  flesh. 

According  to  Mulder,  green  teas  contain  a  larger  quantity 
of  tannin  than  black  teas;  he  states  the  proportion  to  be  17.80 
and  12.88  respectively.  The  bulk  of  the  tannin  is  given  off  by 
infusion  very  quickly.  Sir  William  Roberts,  who  investigated 
this  subject,  wrote:  "Some  persons  have  supposed  that  by  in- 
fusing tea  for  a  very  short  time — only  two  or  three  minutes 
— the  passing  of  the  tannin  into  the  solution  could  be  avoided. 
This  is  a  delusion;  you  can  no  more  have  tea  without  tannin 
than  you  can  have  wine  without  alcohol."  It  would,  however, 
seem  to  be  equally  proved  that  more  tannin  is  given  off  by 
long  infusion. 

Some  experiments  with  reference  to  this  point  were  made 
by  Dr.  Hale  White,  and  recorded  in  the  "British  Medical 
Journal,"  1889. 

"A,  was  the  finest  Assam;  B,  the  finest  China;  C,  common 
Congou;  no  green  of  any  kind  being  used." 

Percentage  of  tannin  by  weight       Percentage  of  tannin  by  weight 
Mark  of  sample.  extracted  by  infusion  for  extracted  by  infusion  for 

3  minutes.  15  minutes. 

A  11.30  17.73 

B  7.77  7.97 

C  9.37  11.15 

It  is  therefore  evident  that  an  infusion  of  tea  cannot  be 
made  -without  its  containing  tannin,  notwithstanding  the 
statements  to  the  contrary  which  are  made  in  some  quarters; 
and  that  long  infusion  extracts  tannin  and  theine  in  larger 
amounts. 

The  effects  of  tea,  like  alcohol,  upon  the  human  economy 
are  so  diverse  in  different  individuals  that  an  analysis  of  the 
facts  must  be  attempted. 

For  all  practical  purposes  tea-drinkers  may  be  divided  into 
four  groups. 

1.  Those  who  can  drink  tea  in  almost  any  quantity  and  at 
any  hour  with  impunity,  and  sleep  naturally.  This  is  a  very 
limited  class. 

That  the  use  of  tea  is  productive,  in  the  healthy,  of  less 
harm  than  is  popularly  supposed,  seems  evident.  Careful 


Insomnia  and  its   Therapeutics.  151 

inquiries  made  of  twenty  gentlemen  who  had  followed  the  oc- 
cupation of  tea-tasting-  in  London  during-  several  years,  elicited 
the  fact  that  not  one  of  them  suffered  from  sleeplessness;  on 
the  contrary,  they  were  all  good  sleepers.  In  most  instances 
they  affirmed  that  they  slept  better  when  attending-  to  their 
business  than  when  they  were  on  holiday.  These  experts  of 
Mincing-  Lane  taste  and  value,  on  an  average,  at  least  a  hun- 
dred and  fifty  samples  of  tea  every  morning  before  the  auction 
sales  begin.  Some  of  them  complained  that  an  unusually 
heavy  morning's  work  induced  a  sense  of  sinking  in  the  epi- 
gastrium and  nausea,  which  luncheon  relieved.  Not  one  of 
them  was  sensible  of  any  loss  of  taste,  nor  were  they  affected 
with  nervousness.  Three  complained  of  constipation  and  one 
of  diarrhoea.  They  were  unanimously  of  opinion  that  their 
profession  was  not  detrimental  to  health. 

This  evidence,  while  it  goes  to  prove  the  tolerance  of  cer- 
tain persons  to  tea,  must  be  accepted  with  this  reserve,  that 
it  seems  probable  if  any  one  of  these  gentlemen  had  found 
himself  rendered  sleepless  early  in  his  career,  he  would  have 
abandoned  the  calling.  It  is  also  to  be  remembered  that  the 
tasting  is  done  in  the  morning,  and  therefore  is  not  so  likely 
to  disturb  sleep  as  drinking  tea  at  night. 

2.  Those  who  can  drink  tea  of  particular  quality  and  in  fair 
quantity  at  any  hour,  and  sleep  soundly.  These  constitute  a 
class  who  are,  under  certain  conditions,  sensitive  to  certain 
varieties  of  tea,  and  who  occasionally  have  their  sleep  inter- 
fered with  from  this  cause.  For  example,  they  are  rendered 
wakeful  by  green  or  Indian  teas,  or  very  new  teas,  especially 
if  these  are  over-infused.  This,  however,  really  depends  upon 
their  general  health  at  the  time.  When  they  are  overworked 
or  slightly  dyspeptic  they  are  apt  to  suffer  in  this  way.  Many 
of  these  persons  exhibit  idiosyncrasies;  some  can  drink  tea 
immediately  before  going-  to  bed  and  sleep  soundly,  who  would 
be  rendered  wakeful  if  they  took  tea  shortly  before  or  after 
dinner.  This  class  embraces  a  larger  number  than  is  gener- 
ally supposed,  and  they  usually  fail  to  connect  their  sleep  dis- 
turbance with  the  use  of  tea. 

In  such  cases,  the  origin  of  the  wakefulness  having  been 
determined,  two  things  are  necessary.  Attention  should  be 
directed  to  the  health,  so  as  to  amend  the  temporary  derange- 
ment. They  must  be  advised  to  select  a  China  or  Ceylon  tea, 


152  Insomnia  and  its   Therapeutics. 

preferably  the  former,  as  it  contains  less  tannin  (p.  648);  to 
infuse  it  only  five  minutes;  and  not  to  drink  it  too  hot.  It 
might  be  mentioned  that  2  per  cent  of  the  bicarbonate  of  soda, 
as  suggested  by  Sir  William  Roberts,  to  counteract  the  effects 
of  the  tannin,  may  be  added  to  the  tea*  that  is,  about  one 
grain  to  each  ordinary  spoonful. 

3.  This  embraces  a  class  of  persons  who  possess  nervous  sys- 
tems either  congenitally  feeble  or  weakened  by  various  debili- 
tating causes.    For  example,  many  young  persons  of  a  neurotic 
diathesis,  and  neurasthenics  and  d3Tspeptics,  are  peculiarly 
sensitive  to  the  use  of  tea  of  all  kinds,  even  in  small  quantities. 
These  persons  are  liable  to  exhibit  the  same  train  of  symp- 
toms as  accrues  from  the  abuse  of  tea.    In  this  class  the  tea 
is  not  at  fault  at  all;  it  simply  renders  more  apparent  a  de- 
parture from  health  already  existing.     A  man  toiling  into  the 
night  may  be  rendered  wakeful  by  tea,  but  it  must  not  be 
overlooked    that   he   might  have  been  wakeful  without    it. 
There  is  little  doubt  that  tea  has  to  bear  more  blame  than 
it  is  entitled  to.     In  every  case  where  it  appears  to  unduly 
disturb  sleep  the  state   of  the  health  should  be  narrowly 
scanned. 

In  such  cases  the  use  of  tea  must  be  interdicted,  and  means 
adopted  to  remedy  the  enfeebled  condition. 

4.  This  includes  a  number  of  persons  of  both  sexes  and  of  all 
ranks  of  life,  who  have  acquired  a  tea-drinking  habit,  and  who 
suffer  from  sleeplessness  as  a  symptom  of  their  excesses.    The 
symptoms  they  exhibit  are  all  referable  to  the  brain  and 
nervous  system.     These  may  be  stated  thus :  sleeplessness,  or 
sleep  disturbed  by  dreams  or  nightmare;   headache;   irrita- 
bility of  temper,  developing  in  some  instances  into  hysterical 
excitement;    depression;    hypochondriasis;    disorders  of    the 
special  senses,  auditory  and  visual  disturbance  (a  form  of  tea 
amblyopia  has  been  described);  neurosal   palpitation;  dys- 
pepsia;  intestinal  torpor,  with  its  concomitant  symptoms  of 
flatulence  and  constipation;  neuralgia,  and  muscular  enfee- 
blement  and  tremors  follow. 

In  these  cases  the  use  of  tea  must  either  be  abandoned 
altogether  or  reduced  to  the  lowest  possible  point.  If  any  is 
taken  it  should  be  weak,  and  neither  long  infused  nor  too  hot. 
The  following  will  be  found  a  useful  remedy. 


Insomnia  and  its   Therapeutics.  ,153 

3  Liq.  strychn., .    3  i. 

Tinct.  quinin.,  .        .        .        .        .        .     3  vi. 

Spt.  ammon.  arom.,         «        »        .        .        .     3  vi. 

Aq.  chlorof.,     .        .        ,        »        .        ._     ad  §  vi. 
M.    Sig.  Take  a  tablespoonf  ul  thrice  daily  in  water. 

For  four  or  five  nights  four  grains  of  the  monobromide  of 
camphor  may  be  given.  As  tea  is  nob  a  cumulative  poison  it 
is  soon  eliminated  from  the  system. 

[It  may  not  be  out  of  place  to  add  a  few  remarks  on  the 
various  teas  met  with  in  commerce.  For  much  of  the  informa- 
tion they  contain  the  writer  is  indebted  to  Mr.  G.  Morison. 

China  teas  may  be  divided  into  three  large  classes. 

Green  Teas. — These  owe  their  peculiar  properties  to  their 
mode  of  manufacture  rather  than  to  any  constituents  they 
originally  contain.  Black  tea  could  be  manufactured  from  the 
same  leaves,  and  this  would  be  devoid  of  many  of  the  char- 
acteristic properties  of  green  tea.  The  chief  varieties  are 
Pinhead  Gunpowder,  Young  Ifyson,  Gunpowder  and  Hyson. 
The  first  two  are  the  finest.  They  are  now  little  used  in  this 
country.  Practically  they  are  not  put  into  blended  teas  except 
by  special  request.  Consequently,  the  sleeplessness  induced 
by  some  teas  is  not  to  be  largely  accounted  for  by  the  presence 
of  green  tea.  A  large  proportion  of  the  green  tea  sold  in 
London  for  home  use  is  consumed  in  the  district  of  which  Not- 
tingham is  the  centre. 

Scented  Teas. — These  consist  of  Caper,  Canton,  and  Foo- 
chow,  Orange  Pekoes,  and  Oolong.  The  first  two  are  scented 
with  jessamine,  orange  blossom,  etc.  Tea  very  readily  absorbs 
the  flavor  or  perfume  of  adjacent  articles.  These  scented 
teas,  which  are  tolerabty  astringent,  are  used  chiefly  in  Eng- 
land for  blending  purposes,  imparting,  as  they  do,  point  and 
pungencjr.  They  are  most  largely  consumed  in  the  great 
centres  of  Birmingham,  Manchester,  and  Nottingham. 

Black  Teas. — These  teas  are  divided  into  two  large  classes, 
Kaisow  and  Moning,  which  are  again  subdivided. 

Kaisow :  this  embraces  the  Seumoo,  Sueykut,  Ching  Wo, 
Paklin,  Lapsen-Souchong,  Paklum,  and  Newmake. 

Moning :  this  includes  Kintuck,  Ningchow,  Oonfa,  Kutoan, 
and  Shamtam,  the  last  name  suggesting  the  lowest  quality. 

The  names  of  many  familiar  teas  will  be  found  wanting 


154  Insomnia  and  its  Therapeutics. 

from  these  lists,  for  the  reason  that  they  have  disappeared 
from  commerce.  The  black  teas  of  China  are  much  used  in 
Great  Britain.  They  are  not  too  astringent.  The  better 
qualities  are  full-bodied  and  aromatic.  The  Ching  Wo  and 
Kintuck  have  probably  the  most  flavor. 

Indian  Teas. — These  are  in  great  request  in  this  country. 
They  probably  represent  one-half  of  the  whole  tea  consumed. 
They  come  principally  from  Assam,  Cachar,  Sylhet,  Darj  eel- 
ing-,  andKangra  Valley,  although  a  quantity  also  comes  from 
Neilgherry  and  Travancore. 

They  are  all  more  astringent  than  China  teas ;  the  Assam 
most  of  all  (see  p.  648).  The  Cachar  and  Sylhet  are  not  so 
pronounced  in  character.  The  Darjeeling,  Neilgherry,  and 
Kangra  Valley  teas  are  chiefly  used  for  flavoring,  though  they 
are  sometimes  drunk  alone,  which  the  others  could  not  well 
be.  Indian  as  well  as  Ceylon  teas  are  divided  into  classes 
according  to  the  leaves  from  which  they  are  obtained.  The 
smaller  or  younger  leaves,  being  more  succulent  than  those 
which  are  fully  grown,  yield  the  finest  teas.  In  order  of  value 
they  are  met  with  in  commerce  as  Broken  Pekoe,  Pekoe,  Pekoe- 
Souchong,  and,  the  lowest  quality,  Souchong  or  Congou. 
Broken  Pekoe  contains  the  tips,  Pekoe  the  first  three  leaves 
of  the  plant,  Pekoe-Souchong  the  leaves  of  older  growth. 

Ceylon  Teas. — These  are  much  in  request  owing  to  their 
soft,  silky,  and  pleasant  flavor.  They  are  often  drunk  with- 
out being  blended.  They  are  more  astringent  than  China,  but 
less  so  than  Indian  teas. 

Java  Teas. — These  teas  have  of  late  years  been  imported 
in  considerable  quantity  into  this  country  for  mixing  and 
blending  purposes.  Being  unusually  good-looking  teas,  they 
improve  the  appearance  of  China  and  Indian  teas.  On  ac- 
count of  their  unpleasant  flavor  they  are  seldom  drunk  alone.] 

Tobacco. — Much  difference  of  opinion  exists  as  to  the 
benefits  derived  from  tobacco  in  moderation.  Many  consider 
it  obnoxious,  but,  on  the  other  hand,  it  is  difficult  to  believe 
that  such  a  widely-spread  custom  as  smoking,  carried  on 
through  centuries,  should  be  specially  deleterious. 

Many  aged  persons  have  smoked  throughout  their  lives 
not  only  with  impunity  but  apparently  with  advantage.  In 
the  statistics  accumulated  by  the  Collective  Investigation 


Insomnia  and  its   Therapeutics.  155 

Committee  of  the  British  Medical  Association,  thirteen  out  of 
forty-five  centenarians  used  tobacco.  Seven  smoked  much 
(four  females);  two  smoked  little  (one  female);  three  smoked 
moderately  (one  female);  while  one  chewed  tobacco. 

Used  in  nioderation,  it  probably  promotes  sleep  in  the  ma- 
jority of  persons,  many  finding1  a  pipe  or  cigar  before  going  to 
bed  indispensable.  There  is  a  minority  upon  whom  tobacco 
always  acts  deleteriously,  and  whose  sleep  is  disturbed  by  it. 
This  disparity  depends  upon  the  stability  of  the  nervous  sys- 
tem of  the  smoker,  and  to  some  extent  on  the  strength  of  the 
tobacco. 

The  first  effect  of  tobacco  on  the  nervous  sj^stem  is  that  of 
a  stimulant;  the  second,  that  of  a  depressant.  In  excess  it 
causes  headache,  mainly  occipital;  giddiness;  mental  depres- 
sion; and  in  some  instances  it  impairs  the  senses  of  hearing1, 
smell,  and  vision ;  in  the  latter  case,  amblyopia  and  scotoma 
are  met  with.  Sleeplessness  is  a  frequent  symptom,  and  it 
usually  appears  about  four  A.M.  Depressing-  the  great  centres 
in  the  medulla  oblongata,  it  leads  to  vaso-motor  paresis,  and 
to  defective  innervation  of  the  heart,  lungs,  and  digestive 
organs.  Affecting-  the  spinal  cord  and  nerves,  it  produces 
trembling-  and  weakness  of  the  limbs. 

Sleeplessness  is  due  jointly  to  vaso-motor  paresis,  cardiac 
enervation,  and  digestive  derangements. 

It  is  most  commonly  met  with  in  smokers  who  have  reached 
middle  life,  whose  nervous  systems  are  beginning-  to  feel  the 
strain  of  work,  or  whose  metabolism  is  being  imperfectly  per- 
formed on  account  of  a  defective  liver.  The  diagnosis  is  as- 
sisted by  the  aspect  of  the  patient,  who  generally  presents 
some  symptoms  of  vaso-motor  paresis. 

Treatment. — This  consists  in  avoiding  tobacco.  As  it  is 
not  a  cumulative  poison  it  is  quickly  eliminated  from  the  sys- 
tem. For  a  few  nights  the  wakefulness  may  be  increased,  but 
sleep  will  soon  return.  During  these  nights  the  administra- 
tion of  four  grains  of  the  inonobromide  of  camphor  is  desirable. 
Tonic  remedies  are  called  for  to  restore  the  tone  of  the  nerv- 
ous system  generally. 


CHAPTEE  IX. 

INSOMNIA  DEPENDING  UPON  AFFECTIONS   OF  THE 
ALIMENTARY  CANAL. 

GASTRIC  DYSPEPSIA. 

SLEEPLESSNESS,  more  or  less  pronounced,  is  a  common  if 
not  constant  symptom  of  every  variety  of  digestive  derange- 
ment. It  occurs  in  the  acute  attack  which  follows  an  occa- 
sional indiscretion  in  -eating1;  likewise  in  many  chronic  forms, 
and  in  these  latter  it  may  be  the  sole  symptom  of  the  derange- 
ment. 

Sleeplessness  of  the  most  obstinate  and  intractable  kind 
can  be  initiated  and  perpetuated  by  diverse  dyspeptic  condi- 
tions, so  obscure  in  their  nature  as  to  elude  detection  for 
lengthened  periods  of  time.  In  short,  it  may  be  caused  by 
many  disorders  arising  primarily  in  the  alimentary  tract,  and 
by  others,  induced  secondarily  by  disturbances  (as  fevers,  etc.) 
in  the  economy. 

The  analysis  of  insomnia  from  such  causes  is  so  intimately 
and  inextricably  associated  with  the  whole  question  of  diges- 
tion, that  at  the  risk  of  appearing  to  digress  from  the  subject 
immediately  under  consideration,  it  is  proposed  to  review 
some  points  bearing  upon  the  physiology  and  pathology  of 
the  processes  of  digestion.  This  is  the  more  called  for  when 
we  reject  that  it  is  only  by  unravelling  the  nature  of  the  dis- 
order, and  by  instituting  a  well-matured  plan  of  treatment 
for  its  rectification,  that  the  sleep  disturbance — its  symptom 
— can  be  successfully  alleviated.  To  attempt  to  deal  with 
such  cases  by  means  of  hypnotics  or  narcotics,  the  majority 
of  which  tend  to  derange  the  secretions,  is  worse  than  useless. 
It  is  to  court  failure  and  to  aggravate  the  evil.  For  the  un- 
conscious and  perfect  performance  of  digestion,  certain  condi- 
tions are  essentially  necessary.  Integrity  of  all  the  structures 
concerned :  stomach,  liver,  intestines,  and  the  various  secre- 


Insomnia  and  its   Therapeutics.  157 

tory  glands.  A  vigorous  nervous  system.  A  normal  blood 
supply.  Healthy  secretion.  Suitable  ingesta.  When  either 
one  or  more  of  these  requisites  fail,  digestion  is  imperfect,  and 
consequently  leads,  among  other  evils,  to  insomnia. 

We  must  now  proceed  to  study  the  causes  of  dyspepsia  in 
the  order  given,  with  special  reference  to  their  influence  upon 
the  character  and  amount  of  sleep. 

Defective  Structures. — All  inherent  or  acquired  debility  of 
the  stomach,  as  well  as  any  abnormality  in  the  viscus,  initiates 
dyspepsia.  Among  the  abnormal  conditions  may  be  enumer- 
ated, alterations  in  size,  such  as  contraction  from  prolonged 
fasting  and  other  causes.  Dilatations,  either  primary,  from 
enfeeblement  of  the  muscular  walls,  which  may  not  only  inter- 
fere with  their  contractile  po\ver,  but  permit  of  distention  of 
the  viscus  under  certain  circumstances;  or,  secondary,  from 
organic  obstruction  of  the  pylorus.  Atrophy  or  hypertrophy 
of  the  walls,  and  cancerous  growths,  must  be  mentioned;  as 
likewise  affections  of  the  mucous  membrane,  e.g.,  catarrhal, 
inflammatory,  ulcerative,  and  degenerative  changes.  These 
latter  may  not  be  accompanied  by  marked  symptoms,  as  the 
mucous  membrane  (except  near  the  orifices)  is  comparatively 
little  sensitive. 

In  like  manner  all  alterations  in  the  calibre  and  structures 
of  the  intestines  become  disturbing  agents,  while  modifications 
of  the  secretory  glands,  and  impairment  of  the  tissues  of  the 
liver,  uniformly  lead  to  faulty  hepatic,  intestinal,  and  gastric 
digestion. 

When  the  tissues  are  all  inherently  strong,  they  are  capa- 
ble of  discharging  their  functions  easily  and  well;  if  one  is 
weak,  the  strength  of  the  whole  is  impaired. 

Defective  Nervous  Arrangements.  Central. — The  whole 
evolution  of  digestion  is  under  the  dominion  of  special  nervous 
centres,  and  of  cerebro-spinal  and  sympathetic  nerves.  The 
presence  of  food  in  the  mouth  instigates  afferent  impulses 
which  are  transmitted  along  cerebro-spinal  nerves  to  the 
medullary  centres;  these  reflexly  produce  hyperaemia  of  the 
salivary  glands,  and  excite  a  flow  of  saliva.  When  the  food 
passes  into  the  stomach  impressions  similarly  aroused  are  con- 
veyed by  the  vagi,  which  reflexly  institute  congestion  of  the 
gastric  glands,  and  as  the  result  of  the  stimulation,  gastric 
juice  is  poured  out.  Like  arrangements  control  and  regulate 


158  Insomnia  and  its   Therapeutics, 

the  periodic  formations  of  bile,  and  of  the  pancreatic  and  in- 
testinal juices. 

A  stable  nervous  system  is  required  for  the  adequate  in- 
nervation  of  the  secretory  glands,  so  that  the  various  secre- 
tions may  be  normally  excited  (and  not  over-excited)  by  the 
normal  stimuli.  The  medullary  centres  which  control  the 
secretory  functions  are  themselves  dominated  by  the  highest 
centres  in  the  brain.  The  psychical  centres  are  in  concord 
with  the  whole  digestive  metamorphoses,  each  one  reacting 
on  the  other. 

Acute  psychical  disturbance,  e.g.,  fright,  is  able  to  arrest 
digestion  at  any  stage.  It  can  inhibit  the  vaso-motor  adjust- 
ments, and  incite  contraction  of  the  arterioles  of  the  various 
secretory  glands,  and  .so  cause  arrest  of  the  secretions.  In 
the  case  of  the  salivary  glands  this  is  indicated  by  the  dry- 
ness  or  stickiness  of  the  tongue,  which  is  popularly  spoken  of 
as  sticking  to  the  roof  of  the  mouth.  The  gastric  glands 
evince  the  same  disturbance.  The  late  Dr.  Beaumont  has  re- 
corded among  his  observations  upon  the  person  of  Alexis 
St.  Martin  (a  young  Canadian,  the  subject  of  a  gastric  fistula), 
that  mental  emotion  checked  the  secretion  of  the  gastric 
glands,  and  that  the  villous  coat  of  the  stomach  became  dry 
and  red,  and  at  other  times  pale  and  moist,  having  lost  its 
smooth  healthy  appearance. 

Less  sudden  mental  activity,  such  as  overwork,  anxiety, 
grief,  worry,  etc.,  acts  similarly,  and  if  more  slowly,  not  less 
surety.  Sensations  produce  different  effects  in  accordance 
with  their  character.  Depressing  emotions  delay  and  derange, 
while  pleasurable  sensations  quicken  and  promote,  digestion. 
Conversely,  digestive  derangements  react  upon  the  brain, 
causing  depression,  irritability,  and  restlessness,  as  well  as 
headache,  giddiness,  and  disorders  of  the  special  senses. 

From  this  it  is  obvious  that  if  impressions  originated  in 
deranged  processes,  and  conveyed  to  the  brain  during  waking 
moments,  can  occasion  such  decided  effects,  then  sensations 
produced  by  like  phenomena,  and  similarly  transmitted  dur- 
ing sleep,  must  necessarily  disturb  the  repose  of  the  brain, 
and  lead  to  molecular  movements  in  the  cells,  and  to  a  conse- 
quent hypersemia:  this  is  specially  true  when  the  cells  are 
irritable  and  impressionable. 

Everything  that  interferes  with  the  integrity  and  nutrition 


Insomnia  and  its   TJicrapeutics.  159 

of  the  nervous  system  leads  to  digestive  derangements.  This 
is  frequently  seen  in  cases  of  exhaustion  of  that  system  brought 
about  by  insomnia  from  whatever  cause.  It  is  often  notice- 
able in  middle  age,  when  the  effects  of  the  strain  of  life  begin 
to  tell  upon  the  structures.  Many  intractable  dyspepsias, 
characterized  "by  extreme  pain  and  bulimia,  originate  in  the 
enfeeblement  induced  by  fatigue,  excesses,  and  debilitating 
diseases. 

The  nervous  system,  in  addition  to  governing  the  forma- 
tion of  the  various  ferments,  presides  over  the  churning  and 
peristaltic  muscular  movements  of  the  stomach,  which  are 
essential  for  the  efficient  chymification  of  the  food.  These 
movements  begin  shortly  after  the  food  enters  the  viscus,  and 
cease  when  gastric  digestion  approaches  completion,  when  the 
P3'lorus,  relaxing,  permits  the  contents  to  be  discharged  into 
the  duodenum,  where  the  movements  are  propagated  through- 
out the  intestinal  canal.  Although  these  peristaltic  contrac- 
tions are  under  the  control  of  special  ganglionic  plexuses  in 
the  muscular  coats  of  the  stomach  and  intestines,  they  are 
likewise  influenced  by  the  vagi.  Fright  can  arrest  them  alto- 
gether, or  excite  them  so  as  to  produce  diarrhoea,  by  unduly 
hastening  the  transit  of  the  intestinal  contents.  Conversely, 
during  sleep,  disorderly  or  arrested  movements  occurring 
before  the  completion  of  digestion  initiate  sensations  which 
are  transmitted  to  the  brain  and  bring  about  awaking. 
Enervation  of  the  system  impairs  the  movements,  and  this  is 
a  frequent  cause  of  slow  digestion,  constipation,  and  of  flatu- 
lent distention  of  the  stomach  and  bowels. 

Peripheral. — Undue  irritability  of  the  nerve  endings  may 
cause  pain  and  gastric  discomfort.  The  nerves  being  com- 
posed largely  of  fibres,  which  permit  of  'considerable  dispersion 
of  the  nervous  currents,  pain  is  obscurely  and  indefinitely  de- 
scribed and  localized ;  var37ing  from  mere  uneasiness,  a  feeling 
of  weight,  and  gnawing,  to  excruciating — even  agonizing — 
pain;  while  it  may  radiate  through  the  chest  and  abdomen, 
through  the  shoulders  and  down  the  limbs.  The  time  of  its 
onset  in  relation  to  food  is  very  often  indicative  of  its  cause, 
as  in  ulceration.  (It  seems  probable  that  modification  of  the 
terminal  endings  of  the  nerves  causes  the  large  and  abnormal 
appetite  which  occurs  in  some  forms  of  dyspepsia.)  Excessive 
n\uscular  movements  may  be  excited  by  poisons  and  irritating 


160  Insomnia  and  its   Therapeutics. 

ingesta;  or  they  may  be  paralyzed  by  causes,  such  as  peritoni- 
tis, gastric  and  enteric  ulcers.  Locally  limited  by  tight  lac- 
ing, and  the  constrained  postures  necessitated  by  some  occupa- 
tions. Interfered  with  by  growths  in  the  walls  of  the  stomach, 
by  dilatations  of  the  stomach,  and  by  adhesions  in  the  abdo- 
men. 

In  health  the  complex  functions  of  the  nervous  S3rstem 
connected  with  digestion  are  executed  so  unconsciously  that  a 
man  would  not  be  aware  he  possessed  a  stomach  were  it  not 
for  the  recurring  sensations  of  hunger. 

During  sleep,  digestive  functions  are  practically  suspended, 
the  medullary  centres  relax  their  activity,  digestive  fluids  are 
not  secreted,  and  the  movements  of  the  gastro-intestinal  canal 
almost,  if  not  entirely,  cease.  This  cessation  of  movement 
affords  a  strong  argument  against  sleeping  after  meals. 
Everything  which  prevents  the  digestive  quiescence  induces 
disturbed  sleep. 

It  has  already  been  pointed  out  that  external  stimuli  ap- 
plied to  the  body  during  sleep  produce  contraction  of  the 
cutaneous  arterioles  and  a  concurrent  cerebral  hyperaemia. 
Internal  influences  act  in  a  similar  way.  The  vagi  convey 
sensations  arising  from  internal  derangements  to  their  roots 
in  the  medulla,  and  these  sensations,  extending  to  the  adja- 
cent centres,  instigate  cerebral  hyperaemia,  which  awakens 
the  steeper.  For  example,  if  a  man  takes  a  large  and  indi- 
gestible meal  shortly  before  going  to  bed,  when  he  falls  asleep 
the  circulation  of  the  blood  becomes  slower,  and  the  move- 
ments of  the  stomach  abate;  digestion  is  arrested.  Impres- 
sions originated  by  this  interruption  produce,  in  the  manner 
described,  cerebral  congestion  and  consequent  activity,  and 
as  the  influx  of  blood  affects  the  motor  or  psychical  centres,  it 
occasions  diverse  symptoms.  The  sleeper  becomes  restless  and 
dreams,  or  suffers  from  nightmare  or  sleep-walking,  or  he 
may  awake  to  find  himself  feverish  and  oppressed,  and  tossing 
from  side  to  side,  or  turning  round  and  round  as  if  he  were 
trying  to  convert  himself  into  a  wheel.  Eventually,  the  nerv- 
ous impressions  spread  to,  and  affect,  the  centre  for  vomiting; 
under  its  co-ordinating  influence  emesis  occurs,  and  relieves 
the  stomach  of  its  disturbing  contents.  The  origo  mail  being 
removed,  the  cerebral  circulation  becomes  quiet,  and  sleep  re- 
turns. 


Insomnia  and  its   Therapeutics.  161 

When  the  derangement  is  more  pronounced,  sleep  may  be 
prevented;  when  it  is  less  marked,  restlessness  and  dreams 
are  the  only  features.  Many  cases  of  wakefulness,  lasting-  for 
two  or  three  hours  during-  the  night,  are  due  solely  to  arrested 
muscular  movements  in  the  stomach  or  in  the  intestines. 

It  goes  without  saying-  that  such  sleep  disturbance  is  more 
commonly  met  with  in  those  whose  digestive  arrangements 
are  weak,  and  liable  to  become  deranged. 

Dyspepsia  may  be  instigated  through  the  ramifications  of 
the  nervous  system  in  sympathy  with  other  organs.  For  ex- 
ample, gastric  symptoms  are  of  common  occurrence  in  connec- 
tion with  diseases  of  the  heart,  kidneys,  and  uterus,  and  they 
thus  act  secondarily  as  disturbers  of  sleep. 

Abnormal  Vascular ization. — The  constituents  of  the  vari- 
ous digestive  juices  being  obtained  from  the  blood  (the  late 
Dr.  Chambers  wrote:  "The  daily  quantities  of  these  fluids,  as 
estimated,  mainly,  from  the  results  of  Drs.  Bidder  and  Schmidt's 
experiments,  may  be  reckoned,  at  least,  to  equal  the  following  : 
Of  saliva,  3|  pints;  of  gastric  juice,  12  pints;  of  bile,  3|  pints; 
of  pancreatic  juice,  1£  pints;  of  intestinal  juice,  ipint;  mak- 
ing in  all  nearly  three  gallons  "),  it  is  essential  for  the  forma- 
tion of  these  fluids  that  the  glands  which  elaborate  them, 
should,  in  response  to  proper  stimulation,  become  hyperasmic. 
If  the  supply  of  blood  is  deficient  in  quantity  or  altered  in 
quality,  the  constitution  of  the  juices  suffers  corresponding 
modifications.  Coincident  with  the  onset  of  digestion,  a  great 
influx  of  blood  takes  place  into  the  vessels  of  the  stomach, 
which,  besides  contributing  to  the  formation  of  the  gastric 
juice,  stimulates  the  muscular  movements  of  the  viscus. 

Probably  the  consequent  depletion  of  the  distant  parts  ex- 
plains the  chilliness  of  the  extremities,  and  the  drowsiness, 
which  sometimes  follows  a  full  meal. 

If  anything  deprives  the  stomach  of  an  adequate  san- 
guineous supply,  such  as  happens  when  active  brain-work  en- 
tailing hyperaemia  is  continued  during  and  immediately  after 
meals,  digestive  derangements  ensue. 

On  the  other  hand,  abnormal  and  persisting  determination 
of  blood  to  the  stomach  or  intestines  becomes  a  source  of  dis- 
turbance, by  occasioning  catarrhal  and  inflammatory  diseases 
of  the  mucous  membrane  of  the  stomach,  e.g.,  in  alcoholic  ex- 
cess. Dr.  Beaumont  observed  in  St.  Martin  that  stimulating 


1 62  'Insomnia  and  its   Therapeutics. 

liquors  and  overloading-  the  stomach  led  to  these  vascular 
derangements,  occasionally  causing-  red  spots  and  abraded 
patches  on  the  mucous  membrane;  at  other  times,  deep  red 
patches  from  venous  congestion.  In  these  catarrhal  condi- 
tions mucus  is  formed,  which  delays  digestion  by  coating  the 
food  and  preventing  the  gastric  juice  from  acting  upon  it. 

Passive  congestion  of  the  stomach  and  bowels,  depending 
upon  obstruction  to  the  free  return  of  blood  to  the  heart,  such 
as  occurs  in  some  diseases  of  the  heart  and  liver,  occasions 
digestive  troubles,  and  at  times  increased  peristaltic  move- 
ments. 

When  the  blood  supply  is  altered,  as  in  anaemia,  in  which 
there  is  an  insufficiency  of  oxygen-carrying  corpuscles,  or 
when  it  is  imperfectly  aerated  by  vitiated  air,  or  laden  with 
the  materies  morbi  of  a  disordered  metabolism,  as  in  gout,  di- 
gestion is  invariably  imperfect.  Blood  charged  with  peptones, 
digestive  products  (ptomaines?),  or  with  uric  acid,  is  unsuit- 
able alike  for  the  digestive  processes  and  for  cerebral  nutri- 
tion. To  this  subject  we  must  revert  presently. 

In  the  majority  of  Cases  of  insomnia  arising  from  gastric 
dyspepsia  it  seems  almost  certain  that  there  is  no  marked 
mal-nutrition  of  the  cerebral  cells;  consequently,  they  are  not 
unduly  perceptive.  On  the  contrary,  they  are  only  aroused 
into  activity  by  sensations  sufficiently  pronounced  to  disturb 
sleep  under  normal  conditions. 

In  a  minority  of  such  cases,  a  close  study  of  their  peculiar- 
ities, renders  it  probable  that  they  are  brought  about  by  the 
morbid  products  of  a  deranged  digestion  entering  the  circula- 
tion and  so  affecting  the  cerebral  cells  as  to  cause  awaking. 

The  influences  of  such  blood  on  the  bodily  tissues  can  be 
well  studied  in  the  various  affections  of  the  skin,  which  so  fre- 
quently appear  in  their  train. 

Faulty  Secretion. — The  secretions  are  individually  and  rel- 
atively important,  effecting,  as  they  do,  the  chemical  changes 
in  digestion.  If  the  digestive  changes  are  to  be  satisfactorily 
accomplished  in  the  aggregate,  each  ferment  must  in  rotation 
perform  its  proper  and  adequate  share  of  the  work.  The 
saliva  dissolves  the  saline  matters,  and  converts  the  starches 
into  dextrin  and  maltose;  the  gastric  juice  acts  on  the  pro- 
teids  or  the  albuminoids,  and  changes  them  into  true  peptones, 
etc. 


Insomnia  and  its  Therapeutics.  163 

When  food  is  eaten  hurriedly,  and  saliva  consequently  not 
secreted  in  adequate  amount,  a  twofold  error  is  instituted. 
The  food  starches  are  not  broken  up  and  changed  by  the  dias- 
tase into  dextrin,  etc.  When  the  food  is  swallowed,  the  de- 
ficient quantity  of  saliva  fails  to  stimulate  the  flow  of  gastric 
juice,  for,  like  all  weak  alkalies,  it  is  a  powerful  stimulant  of 
that  peptic  fluid.  The  insufficient  gastric  juice  fails  to  con- 
vert all  the  proteids  into  peptones,  so  that  practically  the 
grea.t  bulk  of  the  starches,  albuminoids,  and  fats  are  passed 
undigested  into  the  intestines,  where  the  pancreatic  and  in- 
testinal fluids  have  to  perform,  unaided,  the  whole  metamor- 
phosis. 

In  robust  health  these  secretions  may  be  able  to  overtake 
this  work,  but  when  weakness  leads  to  their  scanty  formation 
they  fail,  and,  fermentation  and  putrefactive  changes  ensuing, 
still  further  complications  follow. 

Secretions  deficient  in  Quantity. — Each  of  the  digestive 
fluids  may  be  secreted  in  too  scanty  amount.  It  will  suffice 
to  illustrate  this  by  referring  to  the  saliva  and  gastric  juice 
only.  They  are  scanty  in  febrile  diseases,  as  well  as  in  some 
affections  of  the  nervous  system. 

Excessive  in  Quantity. — The  saliva  is  increased  in  certain 
exhausted  conditions.  Sir  William  Roberts  believes  that  py- 
rosis is  merely  a  paroxysmal  neurosis,  which  depends  upon  an 
acid  condition  of  the  stomach,  causing  copious  gushes  of  saliva 
into  the  mouth.  In  certain  catarrhal  conditions  of  the  stom- 
ach, e.g.,  the  alcoholic,  saliva  is  formed  in  excess;  it  either 
dribbles  on  to  the  pillow,  or  is  unconsciously  swallowed  during 
sleep.  The  gastric  juice  is  frequently  secreted  in  abnormal 
quantities,  giving  rise  to  acidity  of  the  stomach.  This  appears 
to  be  particularly  the  case  when  the  nervous  system  is  faulty. 

Morbid  in  Quality. — In  fevers  the  saliva  may  be  acid, 
and,  in  consequence,  devoid  of  its  diastastic  power;  this  also 
may  be  the  case  in  diabetes.  The  gastric  juice  occasionallj- 
contains  abnormal  proportions  of  hydrochloric  acid  and  pep- 
sin, or  either  too  much  or  too  little  acid,  the  one  condition 
delaying  digestion  as  much  as  the  other.  In  some  feverish 
states  it  exercises  no  influence  on  digestion  at  all.  Occasion- 
ally organic  acids  may  be  formed  in  the  stomach:  that  of 
acetic  fermentation  will  be  immediately  referred  to;  that  aris- 
ing from  the  fermentation  of  grape  or  cane  sugars,  starches  or 


164  Insomnia  and  its  Therapeutics, 

milk,  forming  lactic  acid,  while  that  depending  upon  the  ran- 
cidity of  fat,  forms  butyric  acid.  Both  these  are  instigated  by 
the  presence  of  organisms,  and  may,  of  themselves,  cause 
catarrhal  conditions  to  arise.  Such  acrid  and  disordered  con- 
tents irritate  the  nerve  endings  and  cause  sensations  inimical 
to  sleep. 

These  fermentative  changes  lead  to  formations  of  large 
quantities  of  gas,  which,  prevented  from  escaping  by  the 
closed  pyloric  opening,  sometimes  lead  to  dilatation  of  the 
stomach. 

Flatulence  usually  indicates  slow  digestion.  Butyric  acid 
causes  heartburn  by  irritating  the  cardiac  end  of  the  gullet. 

We  shall  require,  hereafter,  to  refer  to  derangements  of 
the  biliary,  pancreatic,  and  intestinal  secretions. 

Unsuitable  Ingesta. — All  food  should  have  some  propor- 
tionate relation  to  the  age,  temperament,  and  occupation  of 
the  individual,  and  to  the  weather  and  climate. 

In  the  young,  when  growth  and  waste  are  equally  rapid, 
and  digestion  is  vigorous,  much  food  is  relatively  required;  in 
adult  life,  when  growth  is  completed,  and  waste  and  repair 
alone  need  to  be  daily  balanced,  less  food  is  necessary;  in  the 
aged,  when  repair  is  effected  with  difficulty,  a  yet  smaller 
quantity  of  nourishment  is  wanted. 

Men  of  sanguine  temperament,  usually  possessing  vigorous 
digestions,  have  occasion  for  more  food  than  those  belonging 
to  the  lymphatic  or  neurotic  classes.  The  food  of  neurotics 
should  always  be  carefully  arranged,  because,  while  they  re- 
quire to  be  nourished  up  to  the  limit  of  their  digestive  powers, 
if  that  be  exceeded  it  causes  derangements. 

The  physically  active  need  more  food  than  those  who  pur- 
sue sedentary  occupations.  A  highland  deer-stalker,  trudg- 
ing all  day  in  invigorating  air,  can  consume  and  digest  food 
in  quantity  and  quality  utterly  unsuited  to  a  clerk  spending 
the  bulk  of  his  life  in  an  imperfectly  oxygenated  atmosphere. 
A  man  hunting  five  days  a  week  can  eat  with  impunity  articles 
of  diet  he  cannot  digest  at  all  while  leading  an  inactive  life  in 
town.  A  lady  can  frequently  digest  better  during  the  season 
when  she  is  dancing  for  several  hours  almost  every  night, 
than  when  she  is  leading  a  less  active  life.  In  consequence, 
such  persons  sleep  more  soundly.  Food  should  be  modified 
according  to  the  temperature  of  the  weather,  just  as  it  re- 


Insomnia  and  its  Therapeutics.  165 

quires  adaptation  to  different  climates.  The  Briton  has  found 
by  experience  that  he  can  only  maintain  his  health  when 
residing1  in  extreme  climates  by  adopting1,  in  a  large  measure, 
the  food  of  the  country. 

Overfeeding  is  a  common  source  of  Dyspepsia. — A  man 
who  habitually  eats  more  than  is  required  to  compensate  his 
mental  and  bodily  waste — and  it  is  a  prevalent  error — throws 
a  tax  upon  his  digestion.  While  he  is  vigorous,  and  his  powers 
are  in  excess  of  his  absolute  requirements,  it  may  not  cause 
him  any  inconvenience,  particularly  as  a  certain  proportion 
of  the  food  evades  digestion,  and  escapes  with  the  faeces ;  but 
whenever  anything  occurs,  such  as  overwork,  to  disturb  or 
decrease  his  energies,  digestion  fails,  and  troubles  begin. 

if  the  food  consists  of  a  superabundance  of  albuminoids,  it 
may  not  be  all  chang-ed  into  true  peptones,  and  these  elements, 
putrefying  in  the  stomach,  give  rise  to  eructations  of  sulphu- 
retted hydrogen.  Fats  in  excess  retard  digestion,  and  often 
give  rise  to  butyric  acid  fermentation. 

Unlimited  quantities  of  fluid  are  injurious  by  diluting  the 
gastric  juice;  very  hot  liquids,  though  at  first  stimulating, 
eventually  enervate  the  mucous  membrane.  Iced  fluids  dis- 
turb digestion,  by  contracting  the  arterioles  of  the  stomach, 
and  by  lowering  the  temperature  below  the  point  (98°-100° 
Fahr.)  necessarj7"  for  perfect  digestion. 

Dyspepsia  in  children,  from  eating  rich  and  tempting  food 
in  excess,  is  a  common  source  of  sleeplessness. 

Underfeeding. — Among  the  poorer  classes  indigestion  is 
largely  caused  by  the  habitual  use  of  tea  and  bread,  which 
they  consume  abundantly  on  account  of  their  cheapness;  the 
temptation  to  do  so  being  increased  by  the  facts  that  tea  is 
easily  prepared,  the  appetite  is  appeased,  and  a  feeling  of 
well-being  is  sustained  for  a  long  time,  evidently  by  its  retard- 
ing digestion.  These  persons  are  practically  semi-starved,  as 
such  a  diet  does  not  contain  all  the  essentials  necessary  for 
the  nourishment  of  the  economy. 

Among  the  richer  classes  it  is  not  uncommon  to  meet  with 
instances  in  which  the  amount  of  food  is  voluntarily  limited. 
Afraid  of  growing  stout,  they  curb,  their  appetites,  eat  little 
or  no  luncheon,  and  take  only  a  meagre  dinner;  and  this  habit 
tends  to  grow  until  a  positive  dislike  to  food  occurs.  Such 
men  become  dyspeptic  and  neurasthenic. 


1 66  Insomnia  and  its  Therapeutics. 

Men  actively  engaged  in  business  often  forget  to  eat  lunch- 
eon; the  accustomed  hour  passes  and  with  it  the  appetite 
disappears.  Ladies  are  culpable  in  this  respect.  All  forms  of 
slight  starvation  affect  the  nervous  system,  the  enfeeblement 
of  which  leads  to  dyspepsia  from  defective  innervation. 

Children  suffer  occasionally  from  insufficient  nourishment, 
chiefly  from  improper  feeding,  or  from  the  milk  they  get  being 
defective  in  quality.  They  grow  restless,  feverish,  and  sleep- 
less, and  cry  unceasingly,  the  crying  in  many  cases  being  sug- 
gestive of  the  cause  of  their  discomfort;  they  are  soothed  and 
fall  asleep  when  suitably  fed.  It  seems  probable  that  many 
infants  have  their  sleep  disturbed  by  lying  on  the  left  side 
after  taking  a  full  meal. 

Unsuitable  Food. — Food  insufficiently  and  improperly 
cooked,  as  well  as  that  difficult  of  solution,  causes  dyspepsia. 
The  object  of  cooking  is  to  develop  the  flavor,  and  render  the 
foods  acceptable  to  the  senses  of  taste,  smell,  and  sight,  so 
that  they  may,  through  the  agency  of  the  mind,  as  well  as 
reflexly  through  the  mouth  and  palate,  excite  the  flow  of  the 
various  secretions;  it  also  aims  at  changing  the  structure  and 
composition  of  the  food,  so  as  to  render  it  more  easy  of  diges- 
tion. It  has  the  disadvantage,  in  some  instances,  of  tempting 
the  person  to  eat  too  much;  this  is  specially  the  case  in  those 
who  lead  luxurious  and  inactive  lives. 

Raw  starch  is  exceedingly  difficult  to  digest.  Cooking 
bursts  its  cellulose  capsules,  swells  up  its  contents,  and  exposes 
them  to  the  action  of  the  salivarj7"  ferment  which  transforms 
them  into  maltose.  So  with  vegetable  matters;  they  are 
swelled  up  and  softened  by  boiling,  and  are  thus  more  easily 
acted  upon  by  the  digestive  fluids.  The  texture  of  animal 
food  is  changed  by  cooking,  the  connective  tissue  is  softened, 
and  its  muscular  fibres  lose  their  cohesion;  so  that  it  can  be 
triturated  and  minutely  disintegrated  by  mastication,  and 
prepared  for  gastric  digestion. 

Lumps  of  food  bolted  hurriedly  arrest  gastric  secretion, 
and  so  may  originate  circulatory  modifications  which  may 
induce  wakefulness.  The  looseness  of  texture  in  meat  is  most 
marked  after  an  animal  is  killed,  before  the  after-death  stiff- 
ening sets  in;  and  secondly  after  it  has  been  kept  for  some 
days.  Every  one  can  appreciate  the  difference  in  digestibility 
which  distinguishes  tender,  juicy,  and  well-cooked  beef  from 


Insomnia  and  its   Therapeutics.  167 

that  which  is  tough,  stringy,  and  dry,  though  it  may  have 
been  cooked  with  equal  care.  This  difference  depends  upon 
the  keeping. 

Meat,  poultry,  and  particularly  game  ma3r  be  kept  too 
long;  after  the  textures  are  relaxed  changes  occur,  which  cul- 
minate in  putrefaction.  Such  meats  are  poisonous.  Cheese 
and  many  other  articles  of  diet  undergo  decay  and  become 
noxious. 

All  badly-cooked  meats  are  indigestible.  The  partaking 
of  too  many  articles  of  food  at  one  meal  is  a  frequent  source 
of  trouble.  A  man  may  be  able  to  eat  and  digest  a  full  meal 
of  bread  and  cheese,  who  would  experience  great  discomfort 
from  a  mere  morsel  of  cheese  taken  at  the  end  of  a  large  din- 
ner. It  is  nevertheless  probably  true  that  the  quantity  taken 
has  more  to  account  for  than  the  quality,  if  consumed  in  strict 
moderation.  Many  substances  are  indigestible  and  are  better 
avoided,  such  as  pastry  and  unripe  fruit.  Condiments  and 
hot  spices  are  injurious  in  excess.  Stimulants  taken  to  excess 
cause  h3rperaemia  of  the  stomach  with  increased  secretion  of 
mucus.  Sir  William  Roberts  found  that  spirits  in  modera- 
tion did  not  retard  digestion,  but  that  sherry  did  so  in  a  very 
marked  way;  port,  claret,  hock,  and  champagne  also  did  this 
in  an  increasingly  less  degree  in  the  order  given;  he  found 
that  Burton  ale  retards  digestion,  and  also  tea  and  coffee. 
Spirits  and  wine  give  rise  to  dyspepsia  when  taken  in  an  in- 
judicious quantity,  or  when  many  varieties  are  mixed.  They 
not  unfrequentiy  produce  acetous  fermentation  by  the  trans- 
formation of  the  alcohol  into  aldehyde  after  giving  off  some 
acetic  acid. 

Defective  Arrangement  of  Meals. — Some  people  content 
themselves  with  two  large  meals  daily,  breakfast  and  dinner; 
eventually  they  find  themselves  unable  to  digest  the  latter. 
This  arises  from  defective  innervation  of  the  processes  and 
from  deficient  and  defective  secretions;  their  blood,  the  source 
of  the  secretions,  being  impoverished,  fails  to  furnish  the 
proper  constituents.  After  a  late  and  large  meal  their  condi- 
tion is  one  of  exhaustion  combined  with  a  surfeit  of  food,  which 
is  fatal  to  sleep.  When  the  last  meal  is  taken  too  long  before 
going  to  bed  it  often  causes  sleeplessness  from  want,  though 
there  may  be  no  sensation  of  hunger.  Frequently  repeated 
meals  are  quite  as  injurious  as  too  infrequent. 


1 68  Insomnia  and  its   Therapeutics. 

Each  full  meal  requires  four  or  five  hours  for  its  complete 
digestion;  to  crowd  in  food,  in  the  intervals,  is  to  disturb  and 
render  incomplete  the  digestive  processes.  Taken  for  the 
purpose  of  building-  up  strength,  it  defeats  its  object  and  be- 
comes a  source  of  weakness.  In  health,  all  fillips  between 
meals  are  best  eschewed.  It  must  be  added  that  in  many  dis- 
eases, as  inflammations,  fevers,  etc.,  improper  feeding  gives 
rise  to  deranged  digestion ;  and  this  is  of  importance  in  this 
inquiry,  as  the  sleeplessness  which  so  frequently  attends  these 
ailments  is  more  commonly  due  to  dyspepsia  than  is  supposed, 
and  this  form  of  sleeplessness  only  yields  to  the  treatment  of 
what  may  be  designated  the  subsidiary  disorder.  An  over- 
loaded stomach  in  such  cases  completely  prevents  sleep,  until 
vomiting  relieves  it  of  its  burden. 

Idiosyncrasies. — Many  cases  of  dypspesia  arise  in  persons 
from  eating  articles  of  food,  not  ordinarily  difficult  of  diges- 
tion, but  to  which,  from  some  peculiarity  in  their  constitution, 
they  are  intolerant.  Many  seem  to  be  unable  to  digest  fat, 
milk,  eggs,  cheese,  shellfish,  mackerel,  onions,  and  such  like 
common  dietetic  articles,  and  if  perchance  they  partake  of 
them  it  is  at  the  cost  of  sleep.  The  majority  of  persons  who 
exhibit  such  idiosyncrasies  are  either  neurotic  or  gouty.  They 
suffer  most  in  advancing  years.  They  display  a  like  intoler- 
ance to  the  use  of  many  drugs,  so  that  their  medication  is 
rendered  difficult. 

Having  thus  touched  upon  some  of  the  causes  of  disordered 
digestion,  a  passing  reference  must  be  made,  from  a  diagnos- 
tic standpoint,  to  a  few  of  the  symptoms  which  usually  char- 
acterize the  recognized  forms  of  gastric  derangement. 

Symptoms  of  Dyspepsia. — The  tongue  is  large,  teeth- 
indented,  sodden,  and  covered  by  a  white  fur  in  derangements 
arising  from  atonic  conditions  of  the  system;  it  is  clean  and 
froth}7  in  neurasthenic  states.  It  is  foul  and  thickly  furred, 
with  red  tip  and  prominent  papillae,  and  associated  with  red- 
ness of  the  gums  and  throat  and  dryness  of  the  lips,  in  catar- 
rhal  affections  of  the  stomach.  When  the  catarrh  has  arisen 
from  alcoholic  excess,  the  tongue  trembles  on  being  protruded. 
It  is  clean,  red,  and  glazy  in  certain  cases  of  irritative  dyspep- 
sia; and  coated  with  a  blankety  fur  when  derangement  de- 
pends upon  excessive  smoking. 

The  breath  is  offensive  in  catarrhal  conditions,  and  more 


Insomnia  and  its   Therapeutics.  169 

or  less  heavy  in  all  derangements,  the  mouth  having",  in  many 
cases,  a  clammj'  disagreeable  taste  in  the  morning-. 

The  appetite  is  increased  in  neurasthenic  dyspepsia  to  such 
an  extent  as  to  amount,  in  some  cases,  to  a  craving-  for  food, 
which  eating-  and  drinking-  temporarily  alleviate. 

It  may  be  increased  in  certain  catarrhal  states,  in  which 
there  is  usually  a  preference  for  highlj" -seasoned  dishes  and 
savories,  thirst  being-  very  marked.  It  is  often  fairly  good  in 
atonic  dyspepsia,  but  thirst  is  uncommon.  It  is  decreased  in 
acute  gastric  catarrh,  and  in  derangements  depending  upon 
diminished  secretions;  while  it  is  perverted  in  hysteria,  preg- 
nancy, etc.,  arising  either  from  central  or  peripheral  irritation. 

Epigastric  discomfort,  depending  upon  the  accumulation 
of  gas  in  the  stomach,  and  amounting  to  a  sensation  of  dis- 
tention  and  oppression,  is  common  in  atonic  dyspepsia,  when 
the  muscular  movements  of  the  viscus  are  sluggish,  two  or 
three  hours  after  meals.  •  It  may  be  so  marked  as  to  require 
the  clothes  to  be  loosened  for  its  relief;  occurring  during  the 
night,  it  leads  to  sleep  disturbance.  The  nature  of  the  eructa- 
tions, voluntary  or  involuntary,  affords  a  guide  to  the  fer- 
mentative process;  the  gas  may  be  tasteless,  simply  carbonic 
acid,  or  sour,  when  the  contents  of  the  stomach  are  acid,  etc. 

Acidity  combined  with  flatulence  is  an  indication  of  slow 
digestion.  The  aciditjr  may  arise  from  an  excessive  secretion 
of  gastric  juice,  or  from  the  formation  of  an  abnormal  acid. 

Pain  ranges  from  mere  discomfort,  which  is  seldom  want- 
ing in  any  case,  up  to  severe  excruciating  pain.  It  is  most 
severe  in  the  neurosal  complaints,  and  in  central  affections, 
such  as  hypochondriasis.  The  pain,  in  acute  catarrhal  ail- 
ments, is  variable,  but  it  can  always  be  elicited  by  pressure. 
In  chronic  gastric  catarrh  it  may  amount  only  to  uneasiness, 
and  be  temporarily  relieved  by  eating  and  drinking.  Pain 
from  ulceration  comes  on  quickly  after  food  is  taken;  from 
chronic  atonic  dyspepsia,  in  two  or  three  hours,  being  mostly 
associated  with  defective  secretions.  In  functional  disorders 
it  is  not  aggravated  by  food ;  when  it  comes  on  during  the 
night  it  is  usually  from  arrested  or  irregular  muscular  move- 
ments, and  from  distention  with  flatulence.  Pain  referred  to 
the  stomach  is  not  always  due  to  derangements  of  digestion. 

Vomiting  occurs  in  acute  gastric  catarrh  shortly  after 
eating,  and  is  preceded  by  nausea;  in  chronic  catarrh  it  is 


170  Insomnia  and  its   Therapeutics. 

common  in  the  morning1,  as  it  is  in  the  reflex  irritation  of 
pregnancy.  It  occurs  in  ulceration  almost  immediately  after 
taking  food,  and  in  slow  digestion  after  the  lapse  of  two  or 
three  hours;  in  dilatations  and  in  pyloric  obstruction  at  dis- 
tant intervals  and  in  excessive  quantities.  The  vomited  mat- 
ters should  always  be  scanned  for  mucus,  abnormal  ferments, 
sarcince  ventriculi,  bile  and  blood.  In  affections  where  bile 
regurgitates  into  the  stomach,  it  destroys  digestion  by  ren- 
dering the  acid  contents  alkaline,  and  it  stains  the  vomited 
matters  green. 

The  bowels  are  often  loose  in  catarrhal,  and  constipated  in 
atonic  and  neurasthenic  conditions. 

The  general  symptoms  vary;  restlessness,  irritability,  and 
headache  being  associated  with  gastric  catarrh,  while  languor 
and  despondency,  increased  after  eating  and  accompanied  by 
a  tendency  to  flush,  are  the  concomitants  of  atonic  derange- 
ments. 

The  complexion  is  often  muddy,  the  skin  is  dry  and  harsh, 
sometimes  flabby  and  greasy,  or  affected  by  eczema  or  other 
form  of  skin  disease.  The  hands  and  feet  are,  in  many  in- 
stances, cold  and  chilly  during  the  day,  and  hot  and  burning1 
at  night.  Cardiac  and  respiratory  disturbances  take  the 
form  of  palpitation,  intermission, and  irregularity  of  the  heart's 
action;  and  of  cough  and  asthmatic  seizures,  which  are  most 
apt  to  come  on  at  night  during  sleep.  The  urine  may  be  acid 
and  scanty,  containing  uric  acid,  urates  or  phosphates  in  ex- 
cess, oxalate  of  lime  crystals,  or  traces  of  albumin  and  sugar, 
the  latter  commonly  from  improper  ingesta. 

Hiccough,  eructations,  heartburn,  acidity,  burning  sensa- 
tions in  the  hands  and  feet,  are  all  able  to  prevent  sleep;  while 
flatulent  distention  of  the  stomach  and  bowels,  by  embarrass- 
ing the  action  of  the  diaphragm,  and  mechanically  impeding 
the  movements  of  the  lungs  and  heart,  may  disturb  sleep,  and 
cause  dreams,  nightmare,  or  sleep-walking.  Painful  sensa- 
tions are  likewise  inimical  to  sleep. 

Thus  the  forms  and  symptoms  of  digestive  derangements 
which  give  rise  to  insomnia  are  numerous.  In  many  instances 
no  difficulty  exists  in  the  diagnosis,  but  in  others  it  is  not 
so.  It  then  requires  persevering  investigation  to  deduce  its 
genesis,  and  it  is  sometimes  surprising  how  little  assistance 
is  derived  from  the  patient  or  his  history.  Seeking  advice  for 


Insomnia  and  its   Therapeutics.  \J\ 

sleep  disturbance  of  long1  duration,  he  may  affirm  that  his 
digestion  is  perfect,  and  repudiate,  even  indignantly,  any  sug- 
gestion to  the  contrary;  and  yet  upon  pushing  the  inquiry  a 
confession  is  elicited  that  for  some  years  he  has  been  slightly 
languid,  prone  to  flush,  and  somewhat  flatulent  after  eating, 
and  not  hungry  in  the  morning.  Directing  treatment  to  these 
symptoms  the  insomnia  disappears. 

When  indigestion  can,  in  waking-  moments,  cause  such  cir- 
culatory derangements  as  to  lead  to  pronounced  flushing,  it  is 
not  surprising  that  during  sleep  it  can  set  up  cerebral  hy- 
peraemia. 

Treatment. — The  treatment  of  dyspepsia  must  necessarily 
vary  with  the  cause.  As  digestive  derangement  is  frequently 
a  local  indication  of  some  departure  from  health,  rather  than 
a  primary  affection,  the  treatment  requires  to  be  conducted, 
in  the  majority  of  instances,  on  general  as  well  as  on  special 
principles. 

Everything  which  tends  to  strengthen  and  impart  tone  to 
the  nervous  system,  and  to  improve  the  chemical  metamor- 
phoses of  the  formation  and  depuration  of  the  blood,  amelior- 
ates the  symptoms.  It  is  certainly  the  right  way  to  begin 
the  treatment;  but  whatever  course  may  be  adopted  the  fol- 
lowing rules  apply  to  all  cases. 

It  is  essentially  necessary  that  all  dyspeptics  should  eat 
slowly  and  deliberately.  The  masticatory  movements  not 
only  increase  the  pulse  rate  and  the  flow  of  blood  to  the  secre- 
tory glands,  thus  inciting  the  active  formation  of  the  juices, 
but  they  incorporate  the  starches  with  the  saliva,  and  disin- 
tegrate the  albuminoid  foods  to  prepare  them  for  further  di- 
gestion. Everything-,  therefore,  which  prevents  complete  mas- 
tication should  be  remedied,  and  the  gums  and  teeth  kept  in 
good  working  order.  It  is  important  to  eat  in  moderation; 
the  majority  of  people  probably  eat  too  much.  Eating  slowly 
is  practically  equivalent  to  eating  less,  for  the  appetite  is 
appeased  by  a  smaller  quantity,  while  that  taken  is  more 
thoroughly  digested  and  assimilated.  The  food  of  every-day 
life  should  be  arranged  so  as  to  embrace  suitable  and  propor- 
tionate quantities  of  nitrogenous,  carbonaceous,  saccharine, 
and  oleaginous  elements;  and  these  (as  has  been  already 
pointed  out)  should  bear  some  relation  to  the  age,  tempera- 
ment, occupation,  etc.,  of  the  individual,  and  to  the  strength 


172  Insomnia  and  its  Therapeutics. 

of  his  digestive  powers.  Morevover,  the  food  ought  to  be 
varied  from  day  to  day.  This  promotes  digestion  and  assimi- 
lation in  a  very  marked  way.  Many  errors  are  committed  in 
this  respect.  As  an  example,  the  writer  may  mention  the 
case  of  a  lady  of  advanced  age,  who  consulted  him  some  years 
ago  for  serious  sleep  disturbance  dependent  on  a  skin  affection ; 
on  inquiry  he  found  that  for  a  few  years  she  had  dined  every 
day  upon  salt-fish  pie.  In  such  a  case  the  wonder  was,  not 
that  she  was  suffering,  but  that  she  kept  so  long  free  from 
disease. 

The  dietary,  then,  must  be  carefully  considered  in  every 
case,  so  that  the  patient  may  be  told  distinctly  what  to  eat 
and  what  to  avoid.  As  a  rule,  liquids  should  be  taken  at  the 
end  of  meals  only.  Meals  should  be  fixed  at  regular  intervals, 
the  last  being  taken  not  earlier  than  three  hours  before  bed- 
time, and  composed  of  digestible  articles. 

Good  cooking  is  of  paramount  importance.  I*t  is  useless 
to  prescribe  a  special  diet  if  it  is  badly  prepared.  If,  for  ex- 
ample, a  sole  (which  is  delicate  and  light)  is  cooked  in  luke- 
warm oil,  so  as  to  be  thoroughly  saturated  with  grease,  it  is 
rendered  most  obnoxious.  Roasting,  broiling,  and  grilling  are 
the  best  forms  of  preparation,  but  these  require  the  cook's  art. 
Boiling  and  stewing  come  next.  Frying  and  hashing  are  to 
be  avoided  as  unsuitable.  Dyspeptics  should  never  eat  re- 
cooked  meat. 

Fresh  meat  should  be  well  kept,  and  the  lighter  and  more 
digestible  varieties  preferred.  Well  cooked  and  pleasantly 
flavored,  it  stimulates  the  flow  of  the  salivary  and  gastric 
juices,  which  in  their  turn  influence  the  gastric  movements, 
for  the  muscular  activity  is  in  ratio  to  the  acidity  of  the  con- 
tents of  the  viscus.  Lemon  juice  with  fish  and  the  judicious 
use  of  condiments  have  advantages.  The  most  easily  digested 
fishes  and  vegetables  should  be  selected.  Mutton,  poultry, 
and  game  are  the  most  admissible  meats.  Fats  and  fatty 
meats  and  fishes  are  best  eschewed,  especially  when  they  are 
hot;  and  also  veal,  pork,  and  hard  salted  meats.  Clear  soups 
in  moderation  rather  aid  than  hinder  digestion;  in  other  in- 
stances, all  liquids  increase  discomfort.  Vegetables  and 
starches  should  be  thoroughly  cooked;  stale  bread,  toast  and 
biscuit  crumble  easily,  and  are  therefore  to  be  chosen.  New 
bread  is  very  obnoxious.  Potatoes  should  be  eaten  sparingly. 


Insomnia  and  its  Therapeutics.  173 

Boiled  milk  diluted  with  water,  lime  water,  or  peptonized, 
has  a  large  field  of  usefulness.  Koumiss  is  excellent,  and  can 
easily  be  prepared  at  home. 

Spirits,  wines,  and  malt  liquors,  if  they  seem  to  promote 
digestion,  may  be  allowed,  but  these  require  consideration  in 
each  case.  A  small  quantity  of  whiskey  or  brandy  in  an  alka- 
line effervescing"  water  toward  the  end  of  a  meal  is  frequently 
a  distinct  aid  to  digestion,  particularly  when  cold  extremities 
and  drowsiness  result  from  eating.  Claret  and  champagne  in 
other  cases  suit  better.  When  prescribed  it  must  be  in  quan- 
tities far  short  of  that  which  could  induce  gastric  catarrh. 

Many  dyspeptics  get  into  a  bad  habit  of  eschewing  every 
article  of  diet  which  causes  them  inconvenience;  this  must  be 
discouraged.  Eating  "down"  seldom  answers. 

All  severe  muscular  exercise  or  mental  work  immediately 
before  or  after  eating  is  undesirable,  and  is  certainly  incom- 
patible with  good  digestion. 

The  Turkish  bath  taken  twice  or  thrice  a  week  at  suitable 
hours  is  most  useful.  The  effects  of  dyspepsia  on  the  integu- 
ment are  so  marked  that  in  most  cases  an  unusual  amount  of 
epidermis  peels  off  in  the  process  of  shampooing.  A  morning 
bath  regulated  to  the  strength  of  the  patient,  and  sea-bathing, 
show  their  influence  upon  the  appetite  and  digestive  powers, 
and  therefore  are  to  be  recommended. 

Exercise  short  of  fatigue  is  an  exceedingly  valuable  adjunct 
to  treatment;  in  every  case  it  must  be  proportionate  to  the 
patient's  stamina.  The  use  .of  dumb-bells  or  clubs  after  the 
morning  bath  is  advantageous,  quickening  as  it  does  the  cir- 
culation of  the  blood  through  the  whole  muscular  system,  and 
toning  the  abdominal  muscles,  by  which  the  processes  of  di- 
gestion are  invigorated.  These  processes  are  still  more  braced 
by  exercise  in  the  open  air;  that  follows  necessarily  from  the 
recuperation  of  the  nervous  and  circulatory  systems  which  is 
brought  about.  Walking  and  cycling,  tennis  and  golf,  shoot- 
ing and  fishing,  are  usually  useful  in  different  cases,  but  riding- 
is  par  excellence  the  most  healthful  form  of  exercise.  Lord 
Palmerston  happily  put  it,  "  that  the  outside  of  a  horse  was 
the  best  thing  for  the  inside  of  a  man." 

Change  of  air  and  scene  is  sometimes  called  for.  Diges- 
tion and  nutrition  being  accomplished  more  easily  and  per- 
fectly on  dry  porous  soils,  an  improvement  takes  place  which 


174  Insomnia  and  its   Therapeutics. 

permits  of  amended  sleep ;  this  is  specially  true  of  dry  elevated 
places.  For  such  patients,  there  are  many  suitable  climates 
in  Britain  and  abroad,  but  in  advising  change  the  peculiarities 
of  each  case  must  be  specially  considered  with  reference  to  the 
particular  resort.  Change  of  air  being  the  most  expensive 
remedy  that  can  be  prescribed,  care  is  requisite  for  its  precise 
recommendation. 

In  addition  to  the  general  regimen  and  dieting  it  is  often 
necessary  to  treat  symptoms. 

Flatulence,  with  sensations  of  oppression  and  distention 
in  the  epigastrium,  and  often  accompanied  by  eructations,  was 
deemed  by  the  late  Dr.  Leared  to  depend  upon  impaired  mus- 
cular movements  of  the  stomach  and  bowels,  consequent  upon 
enervation.  This  is  the  reason  that  the  enfeebled,  the  anaemic, 
and  the  neurasthenic  are  so  often  afflicted  with  flatulence. 

Eructations  of  Gas. —  When  these  occur  the  nature  of  the 
gas  affords  indications  for  suitable  treatment.  When  they 
are  acid,  the  starches  and  sugars,  which  are  easily  changed 
into  lactic  acid,  should  be  limited;  when  they  are  acrid  and 
oily,  the  fats  must  be  diminished  in  quantity;  when  composed 
of  sulphuretted  hydrogen,  the  albuminoids  ought  to  be  cur- 
tailed; when  they  are  tasteless,  and  caused  by  eating  unripe 
fruit,  badly-cooked  vegetables,  or  by  the  use  of  peas  or  beans, 
these  obnoxious  articles  should  be  avoided.  Remedies  which 
will  give  tone  to  the  nervous  centres,  and  increase  the  acidity 
of  the  chyme,  are  valuable.  Weak  alkalies  with  strychnine 
are  usually  the  most  efficacious.  • 

IJ  Bicarb,  potass., 3  iij. 

Tinct.  nucis  vom., 3  ij. 

Tinct.  cardam.  co.,          .        .        .        .        .     3  vi. 
Aquam, ad  §  vi. 

M.  Sig.  Take  a  tablespoonful  in  water,  before  meals,  thrice 
daily. 

An  acid  given  after  meals  attains  the  same  object,  particu- 
larly if  it  be  combined  with  pepsin.  The  following  pill  suits 
well: 

$  Sulph.  quinin., 

Acid,  carbolic,  crys., 

Ext.  nucis  vom., aa  gr.  ss. 

Pepsin,  porci, gr.  iiss. 

Ft.  pil.  i.     Sig.  One  before  meals  at  which  meat  is  taken. 


Insomnia  and  its   Therapeutics.  175 

For  immediate  relief  from  distention,  charcoal  in  capsules, 
naphthalin  in  doses  varying1  from  gr.  v.  to  gr.  x.,  or  sodium 
sulpho-carbolate,  gr.  x.  to  gr.  xv.,  are  all  effective. 

The  bowels  in  all  cases  should  be  carefully  attended  to, 
and  when  necessary  acted  upon  by  means  of  aperients,  such 
as  rhubarb,  infusion  of  senna  pods,  or  cascara  sagrada. 

Acidity  may  depend  primarily  upon  excessive,  scanty,  or 
disordered  secretion  of  the  gastric  juice.  An  acid,  such  as 
dilute  nitric  acid,  or  the  oxide  of  silver,  given  before  meals, 
acts  as  an  astringent.  When  the  acidity  depends  upon  the 
formation  of  an  abnormal  acid,  the  starches,  sugars,  and  fats 
must  be  carefully  and  judiciously  managed,  and  tea  and  coffee 
must  be  sparingly  taken.  Washing  out  the  stomach  by 
means  of  emetics  and  copious  draughts  of  warm  water  every 
night  for  three  or  four  nights  is  an  efficacious  method  of  rid- 
ding the  stomach  of  abnormal  ferments.  It  is  marvellous  to 
witness  the  improvement  that  follows.  The  last  three  patients 
to  whom  the  writer  prescribed  this  treatment  improved  at 
once,  and  gained  considerably  hi  weight.  The  first  gained 
twent\'-two  and  a  half  pounds  in  three  months;  the  second, 
eight  and  a  half  pounds  in  a  month;  and  the  third,  six  and  a 
half  pounds  in  the  same  time;  in  each  instance  they  were 
sleeping  soundly  and  well  when  they  passed  out  of  observa- 
tion. For  immediate  relief : 

#  Acid,  carbolic,  crys.,  .       ,        .  ,    gr.  xij. 

Liq.  bismuth.,      .        .        .        .        .        .     3  x. 

Glycer., 3vi. 

Aquam,        .        .        .        .        .        .      ad  fvi. 

M.    Sig.  Take  a  tablespoonful,  in  water,  for  a  dose. 

Or, 

$  Carb.  bismuth., gr.  x. 

Bicarb,  sodii, gr.  vi. 

Pulv.  aromat.  co. gr.  iij. 

Ft.  pulv.  i.  .  M.    Sig.  Take  one  for  a  dose. 

Spanish  juice  is  a  serviceable,  if  homely,  antidote.  It  is  spe- 
cially useful  when  the  secretions  are  perverted,  and  its  efficacy 
is  enhanced  by  sipping  hot  water.  Widely  different  opinions 
have  been  expressed  as  to  the  action  of  this  remedy,  some  be- 
lieving that  it  relieved  solely  by  stimulating  an  increased  flow 


176  Insomnia  and  its  Therapeutics. 

of  alkaline  saliva,  which  being  swallowed,  neutralized  the  acid 
contents  of  the  stomach;  while  others  have  pointed  out  that 
if  that  were  its  only  modus  operandi  cane  sugar  would  act 
equally  well.  Dr.  George  Keith,  who  advises  its  use  as  a 
hypnotic,  points  out  that,  as  a  matter  of  observation,  although 
cane  sugar  may  in  this  way  temporarily  relieve,  the  acidity 
is  speedily  aggravated;  which  never  occurs  after  liquorice. 
Spanish  juice  seems  also  to  exert  a  soothing  influence  over 
the  mucous  membrane  of  the  stomach,  as  the  liquid  extract  of 
liquorice  likewise  does  in  a  lesser  degree  (see  below).  What- 
ever may  be  its  precise  mode  of  action,  its  usefulness  in  a 
large  number  of  cases  is  undoubted.  It  is  most  conveniently 
prescribed  in  the  form  of  Pontefract  cakes. 

Pain.—  When  it  is  neurosal,  arsenic  with  belladonna  should 
be  prescribed.  A  case  lately  under  treatment  exemplifies  a 
usual  experience.  A  lady,  sleepless  for  months,  came  suffer- 
ing from  severe  and  persistent  gastric  pain  with  considerable 
emaciation;  she  had  lost  nearly  two  stones  in  weight.  One 
dose  of  morphine  and  atropine  having  been  taken  at  night, 
which  secured  a  sound  sleep,  she  was  advised  to  take  a  mix- 
ture of  arsenic  and  belladonna;  when  forthwith  she  lost  her 
pain,  regained  sleep,  and  made  an  excellent  recovery. 

When  it  depends,  as  it  frequently  does,  upon  scanty  secre- 
tions, weak  alkalies  before  meals,  and  pepsin  after,  answer 
well.  Where  the  peripheral  endings  of  the  gastric  nerves  are 
irritable,  small  doses  of  morphine,  dilute  hydrocyanic  acid, 
and  bismuth  are  called  for.  In  ansemie  cases  the  following  is 
an  excellent  formula : 

IJ  Liq.  bismuth., f  i. 

Cit.  ferri  ammon., 3ij. 

Acid,  hydrocyan.  dil., TH,  xvi. 

Ext.  glycyrrh.  liq., 3  ss. 

Spt.  chlorof., ill  viij. 

M.  Sig.  Take  a  teaspoonful  in  water,  thrice  daily,  before 
meals. 

The  liquorice  extract  was  originally  introduced  to  modify 
the  disagreeable  taste,  but  it  added  to  the  efficacy  of  the  mix- 
ture. 

Pain,  awaking  the  patient  at  night,  must  be  relieved  by 
opiates,  antispasmodics,  and  poultices. 


Insomnia  and  its  Therapeutics.  1 77 

Vomiting  of  frequent  recurrence  requires  treatment.  It 
is  sometimes  arrested  by  counter-irritation  and  simplifying1 
the  food ;  restricting1  it  to  ice,  iced  champagne,  milk  and  lime 
water,  or  koumiss.  Among  the  most  suitable  remedies  may 
be  mentioned  minim  doses  of  ipecacuanha  wine,  dilute  hydro- 
cyanic acid  with  calumba,  cerium  oxalate,  bismuth  carbonate, 
magnesium  salicylate,  or  the  hypodermic  injection  of  mor- 
phine. Cocaine  is  sometimes  useful.  Rest  in  bed  is  always 
essential  in  obstinate  cases. 

Hiccough  usually  yields  to  a  mustard  plaster  externally 
and  an  alkaline  mixture  internally.  When  these  fail,  ft[  v.  of 
chloroform  on  a  knob  of  sugar,  or  a  hypodermic  injection  of 
morphine  must  be  given. 

Pyrosis. — The  writer  has  almost  never  required  to  use 
any  other  medicine  than  ferro-alumen  in  3-grain  doses,  with 
ffi  ij.  of  dilute  hydrocyanic  acid;  and  he  has  seldom  been  dis- 
appointed with  the  results. 

Eegurgitation  of  Food. — This  is  relieved  by  arsenic  (Til  ij. 
to  TTI  iij.  of  Fowler's  solution)  before  meals;  likewise  by  the 
following  pill: 

IJ  Ext.  belladon., gr.  £ 

Sulph.  quinin., gr.  i. 

Ext.  hyoscy., gr.  ij. 

Ft.  pil.  i.  Sig.  Take  one  three  times  a  day,  an  hour  after 
meals. 

The  urine  in  many  cases  yields  indications  for  treatment. 

Sleep  usually  returns  with  the  relief  of  the  derangement; 
it  is,  however,  occasionally  useful  to  administer  some  special 
remedy  for  a  few  nights  to  induce  sleep,  and  so  gain  the  bene- 
fit of  its  powerful  recuperative  influence.  Dr.  George  Keith 
advocated  the  use  of  Spanish  juice  at  bedtime  as  an  aid  to 
sleep,  and  that  in  cases  in  which  no  disorder  of  the  gastric 
secretions  existed.  From  six  to  twelve  Pontefract  cakes  is 
the  usual  dose.  The  writer  has  repeatedly  obtained  good 
effects  from  their  use,  while  they  act  as  a  slight  aperient.  In 
some  instances  the  benefit  derived  was  so  striking  that  the 
patients  asserted  they  must  contain  some  opiate.  In  a  variety 
of  cases  they  are  of  undoubted  efficacy.  Here  is  also  a  good 
and  unobjectionable  draught : 


178  Insomnia  and  its   Therapeutics. 

I£  Bicarb,  potass., gr.  xv. 

Tinct.  lupul., 3  i. 

Tinct.  lavand.  co., 3  ss. 

Infus.  anthem., ad  3  ij. 

M.    Sig.  Take  at  bedtime. 

Nutmeg*  too  is  useful.  Spiritus  myristicae  3  ss.,  in  an  ounce 
or  two  of  peppermint  water,  acts  in  a  similar  manner.  Nut- 
meg has  for  centuries  been  credited  with  possessing  hypnotic 
properties,  and  not  without  some  good  reason.  The  late  Dr. 
Cullen,  however,  thought  it  should  not  be  prescribed  in  the 
case  of  persons  with  a  tendency  to  apoplexy. 

Among  the  more  potent  agents  suitable,  may  be  mentioned 
hyoscyamus,  cannabis  indica,  morphine,  codeine,  belladonna, 
etc.;  and  among  the  less  active  (although  of  undoubted  value) 
camphor,  valerian,  the  oil  of  chamomile  flowers,  etc.  It  must 
be  borne  in  mind  that  the  treatment  must  be  directed  to  the 
alleviation  of  the  disorder  which  originates  the  disturbing 
sensations,  and  to  the  lessening  of  the  conductivity  of  the 
sensory  nerves.  Pure  hypnotics  are  useless  for  such  purposes. 


INTESTINAL  DYSPEPSIA. 

In  the  last  section  we  discussed  derangements  chiefly  con- 
nected with  gastric  or  acid  digestion ;  we  have  now  to  consider 
some  which  are  associated  with  intestinal  or  alkaline  diges- 
tion. This  process  is  carried  on  by  means  of  the  bile  and  the 
pancreatic  and  intestinal  juices. 

The  bile  furthers  intestinal  digestion  in  several  important 
respects;  the  following  are  the  chief.  It  is  expelled  from  the 
gall-bladder  when  the  acid  chyme  enters  the  duodenum,  and 
•it  precipitates  the  pepsin  and  any  of  the  proteids  which  have 
only  been  transformed  into  acid  albumin,  instead  of  into  true 
peptones,  and  in  that  way  prepares  them  for  the  subsequent 
action  of  the  pancreatic  and  intestinal  juices.  It  possesses 
feeble  diastatic  properties  which  act  on  the  unchanged  starches. 
It  emulsifies  some  of  the  neutral  fats,  and  aids  in  their  absorp- 
tion, as  fats  pass  through  bile-moistened  membranes  with 
some  facility.  It  acts  as  a  powerful  antiseptic,  and  excites 
the  muscular  contractions  of  the  intestines.  It  is  thus  evident 
that  any  disease  interfering  with  the  formation  of  bile  must 


Insomnia  and  its   Therapeutics.  179 

not  only  induce  disorders  of  intestinal  digestion,  but  lead  to 
mat-assimilation, 

The  pancreatic  juice,  which  is  strongly  alkaline,  contains 
three  important  constituents,  which  combine  the  properties  of 
the  saliva  and  tho  gastric  juice.  These  are,  amylopsin,  tryp- 
siu,  and  steopsin.  The  first  acts  on  the  unchanged  starches, 
And  changes  them  into  dextrin  and  sugar;  the  second  breaks 
up  the  proteids,  and  converts  them  into  peptones;  while  the 
third  saponifies  and  emulsifies  fats.  The  processes  are  largely 
promoted  by  the  intestinal  movements.  The  intestinal  juices 
contain  similar  properties.  Absorption  goes  on  in  the  intes- 
tines through  the  agency  of  the  blood-vessels  and  the  lacteals. 

The  sources  of  intestinal  dyspepsia  are  really  the  same  as 
those  enumerated  as  inducing  gastric  disorders:  Defective 
structures;  defective  innervation;  defective  vascularization; 
faulty  secretions;  faulty  ingesta.  . 

The  most  common  exciting  causes  are  imperfect  salivary 
and  gastric  digestion,  leaving  the  bulk  of  the  chemical  changes 
to  be  effected  by  the  pancreatic  and  intestinal  juices.  In  per- 
sons of  limited  digestive  energy  these  are  insufficient  to  ac- 
complish this  completely ;  hence,  fermentative  and  putrefactive 
changes  occur  which  render  the  contents  of  the  colon  acid, 
and  the  leucin  and  tyrosin  may  be  converted  into  indol  and 
skatol,  substances  from  which  the  faeces  derive  their  odor. 

It  may  be  occasioned  by  a  too  scanty  formation  of  bile ;  or, 
what  is  practically  the  same,  an  excessive  acidity  of  the 
chyme,  neutralizing  the  alkaline  constituents  of  the  bile  and 
pancreatic  fluids,  and  so  terminating  the  alkaline  processes. 
It  is  frequently  excited  by  defective  muscular  movements. 

The  symptoms  of  intestinal  indigestion  may  be  conspicuous 
by  their  absence;  when  they  do  occur  they  differ  from  those 
of  gastric  origin.  They  come  on  some  hours  after  meals,  the 
sensations  being  referred  to  the  right  hypochondrium  and 
umbilical  regions,  rather  than  to  the  epigastric.  The  tongue 
is  coated  with  a  thick  yellowish  fur;  the  breath  is  usually 
heavy,  and  the  appetite  impaired  or  fitful.  There  may  be 
flatulence  in  the  bowels  (borborygmus),  often  in  very  consid- 
erable amount,  the  weakened  intestinal  walls  admitting  of 
great  distention. 

This  accumulation  of  gas  is  due  to  the  decomposition  of 
the  various  aliments,  and  the  gases  being  absorbed  into  the 


180  Insomnia  and  its   Therapeutics. 

blood  leads,  in  some  cases,  to  severe  general  disturbance — 
even  to  collapse.  Pain  is  usually  of  a  griping  or  spasmodic 
nature,  and  yields  to  heat  and  pressure.  Arising  during  the 
night,  it  is  frequently  due  to  arrested  muscular  movements. 
There  may  be  nausea  and  vomiting  from  reflex  irritation,  the 
latter  being  ineffectual,  and  not  attended  by  the  relief  that 
follows  the  vomiting  in  gastric  disturbance. 

The  bowels  are  sometimes  relaxed,  but  generally  they  are 
constipated,  the  motions  being  pale,  dry,  and  offensive;  and  if 
the  pancreatic  secretions  be  faulty,  fat  may  be  detected  in 
them. 

The  urine  is  scanty,  high-colored,  and  either  deposits  uric 
acid  or  urates  on  cooling. 

The  aspect  is  sallow  and  earthy,  the  conjunctivas  tinged 
with  yellow  pigment.  These  patients  look  ill,  they  are  de- 
pressed and  desponding,  and  at  times  hypochondriacal.  Gid- 
diness and  disorders  of  the  special  senses  are  common.  There 
is  often  much  emaciation,  the  nervous  system  feeling  acutely 
the  non-absorption  of  fats,  etc.;  and  as  absorption  of  these 
nutrients  takes  place  in  the  upper  half  of  the  intestinal  canal 
all  derangements  of  digestion  in  that  portion  lead  to  enfeeble- 
ment  and  enervation  of  the  whole  body.  The  heart  and  lungs 
participate  in  this  weakness.  The  blood  badly  formed,  and 
laden  with  waste  products  nourishing  the  tissues  inadequate!}', 
adds  to  the  prostration.  Such  persons  are  apt  to  be  shivery 
and  miserable. 

The  cerebral  cells,  partially  starved,  grow  susceptive,  and 
responsive  to  slight  stimulations;  this  they  show  at  night  in 
sleeplessness  and  restlessness,  the  latter  of  an  almost  exag- 
gerated kind,  compelling  the  patient  to  get  out  of  bed  and 
wander  up  and  down  his  room.  So  marked  is  this,  that  the 
writer,  for  many  years,  has  believed  the  pathogeny  of  fidgets 
to  be  reflex  irritation  excited  by  duodenal  and  intestinal  dis- 
order. 

Intestinal  dyspepsia  is  a  much  more  frequent  source  of 
sleep  disturbance  than  the  gastric  form,  and  one  of  greater 
diagnostic  obscurity,  for  the  reason  that  there  may  be  no 
symptom  to  indicate  abdominal  discomfort;  in  short, no  symp- 
tom other  than  obstinate  wakefulness.  Intestinal  digestion, 
which  is  not  normally  completed  for  some  hours  after  the  in- 
gestion  of  a  full  meal,  is  even  more  slowly  effected  in  such 


Insomnia  and  its   Therapeutics.  181 

patients.  If  sleep  supervene,  and  the  intestinal  movements 
slacken  or  cease,  the  processes  are  interrupted,  and  so  de- 
rangements are  initiated  which  disturb  and  terminate  sleep. 

Many  patients  who  awake  at  one  or  two  o'clock  in  the 
morning,  and  lie  awake  till  five  o'clock,  are  roused  by  intes- 
tinal disturbance,  and  are  kept  from  sleeping  until  the  move- 
ments complete  the  digestive  processes.  Moreover,  the  per- 
sistence of  imperfect  intestinal  digestion,  leading  to  defective 
nutrition,  renders  the  cerebral  cells  abnormally  sensitive  to 
all  disturbing  agencies  in  the  economy.  They  are  thus  per- 
turbed by  insignificant  distant  sensations,  which  in  robust 
health  they  would  not  perceive. 

Treatment. — All  that  was  said  upon  the  treatment  of  the 
general  condition  in  gastric  disorders  applies  here,  exercise 
being  probably  more  called  for,  by  quickening  the  circula- 
tion it  facilitates  the  chyle  currents.  Turkish  baths  are  par- 
ticularly beneficial.  Every  means  calculated  to  improve  in- 
nervation  and  vascularization  should  be  adopted. 

Intestinal  digestion  is  not  easily  impressed  by  medication ; 
practically  it  can  only  be  improved  by  rendering  salivary  and 
gastric  digestion  more  complete.  Where  excessive  acidity  of 
the  gastric  contents  exists,  it  should  be  neutralized  with  lime 
water,  lithium,  or  magnesia.  When  diarrhoea  is  present, 
opium  must  be  given.  Constipation  must  be  relieved.  When 
the  pancreatic  fluid  is  deficient  some  temporary  benefit  may 
be  derived  from  the  use  of  Benger's  pancreatic  liquor  in  lime 
water,  or  mixed  with  sodium  bicarbonate  two  hours  after 
meals;  and  also  from  the  judicious  administration  of  malt  ex- 
tract. Sleep  is  often  improved  by  the  nightly  use  of  massage, 
and  also  by  the  application  of  an  abdominal  compress. 

Heat,  stimulating  the  completion  of  the  digestive  processes, 
favors  the  return  of  sleep.  For  example,  a  bag  containing  hot 
water  applied  over  the  abdomen,  and  a  drink  of  warm  water 
on  awaking,  seldom  fails  to  act  beneficially. 

When  flatulence  is  a  marked  symptom,  the  administration 
of  turpentine  is  desirable.  That  drug  possesses,  in  addition 
to  its  powerful  carminative,  some  hypnotic  properties.  The 
late  Dr.  Warburton  Begbie  recorded :  "  Occasionally  the  oil 
has  been  observed  to  cause  sleep." 

Wakefulness  is  frequently  obviated  by  a  draught  like  the 
following  at  bedtime. 


1 82  Insomnia  and  its   Therapeutics. 

IJ  Bicarb,  potass., gr.  xv. 

Sulph.  sodii, 3  i. 

Tinct.  lupul.,       .     '  .        •        •        •        .    3  i. 

Infus.  anthem.,    .        .        .        .        .       ad  f  ij. 
M.    Sig.  Take  at  bedtime. 

In  other  cases  a  similar  draught,  in  which  TH,  x.  of  the  tinc- 
ture of  belladonna  is  substituted  for  the  sodium  sulphate, 
suits  even  better;  and  a  little  syrup  of  ginger  may  be  added 
to  either.  Such  draughts,  taken  during  the  night  on  awaking, 
often  induce  sleep. 

When  sleep  is  urgently  required  it  is  sometimes  useful  to 
administer  a  hypnotic  for  a  few  nights  to  allow  the  nervous 
system  to  recuperate;  but  as  they  are  obviously  not  curative 
agents,  their  use  must  be  dispensed  with  if  possible.  Hyos- 
cyamus,  tannate  of  cannabin,  and  lupulin  are  the  most  suitable 
hypnotics. 

CONSTIPATION. 

The  contents  of  the  small  intestines  are  liquid.  As  that 
portion  of  the  alimentary  tract  secretes  digestive  fluids 
abundantly,  these  compensate  for  the  withdrawal  of  the 
nutrient  constituents,  which  are  rapidly  absorbed.  The  pro- 
cesses of  secretion  and  absorption  are  therefore  here  balanced. 
The  contents  of  the  large  intestin.e  are  more  consistent,  and  if 
they  are  retained  for  any  length  of  time  they  become  drjr  and 
hard,  for  in  the  large  intestine  secretion  is  limited,  while  ab- 
sorption is  considerable.  The  powers  of  absorption  are  well 
demonstrated  by  the  rapid  way  that  the  rectum  appropriates 
liquid  given  by  enemata.  (See  page  659.)  The  consistency 
of  the  contents  of  the  colon  is  thus  the  result  of  time,  for  if 
they  are  rapidly  passed  from  above  downward,  as  they  are 
in  diarrhoea  and  after  the  administration  of  saline  purgatives, 
the  motions  are  quite  liquid. 

Among  the  causes  of  constipation  must  be  enumerated : 

Defective  structures,  which  comprise  all  lesions  interfering 
with  the  integrity  of  the  intestines.  The  graver  diseases 
include  deep  ulcerations  and  cancerous  growths;  the  more 
trivial,  hemorrhoids  and  fissure  of  anus.  Those  external  to 
the  bowel  comprise  tumors  and  displacements  of  the  womb, 
etc.,  occluding  the  lumen. 

Impaired   nervous   arrangements,  central    or   peripheral. 


Insomnia  and  its  Therapeutics.  183 

Mental  depression  and  organic  cerebral  diseases  frequently 
induce  obstinate  constipation.  Neurasthenic  conditions  and 
the  use  of  some  poisons  in  excess,  lead  to  the  enervation  of  the 
whole  processes  of  digestion,  and  to  a  relaxed  state  of  the 
muscular  system,  with  defective  movements.  It  is  very 
common  to  meet  with  constipation  in  men  and  women  of 
slothful  habits,  who  spend  their  days  in  heated  and  badly- 
ventilated  rooms,  and  who  take  no  exercise.  It  depends 
mainly  upon  an  enervated  condition  of  the  muscles  involved  in 
digestion,  viz.,  the  abdominal,  and  the  intestinal,  and  the  dia- 
phragm. This  relaxed  state  is  ;the  source  of  constipation  in 
many  aged  persons.  The  habitual  neglect  of  the  calls  of  nature 
(which  is  a  common  source  of  constipation)  brings  about  a 
condition  in  which  the  nerves  fail  after  a  time  to  respond  to 
their  normal  stimuli.  Indeed,  any  interference  with  the  in- 
tegrity of  the  nerves  supplying  the  rectum  and  anus,  may 
cause  constipation  by  destroying  the  usual  reflex  arrange- 
ments. The  wrant  of  sleep,  though  mentioned  thus  late,  is  a 
far  more  frequent  source  of  constipation  than  is  generally 
imagined.  It  is  thus  the  cause  of,  as  well  as  the  result  of, 
constipation. 

Abnormal  vascularization :  this  chiefly  depends  on  anasmia 
and  imperfectly  oxygenated  and  deterged  blood,  and  on  dis- 
eases which  retard  the  free  return  of  blood  to  the  heart,  such 
as  obstruction  of  the  portal  circulation.  It  may  also  depend 
on  the  presence  of  poisons,  as  lead. 

Faulty  chemical  changes,  such  as  arise  from  defective 
secretions,  as  occur  in  some  fevers  and  debilitating  diseases, 
or  when  the  system  is  drained  of  excessive  quantities  of  fluid, 
as  in  diabetes,  over-lactation,  etc. 

Faulty  ingesta :  this  includes  food  too  astringent,  or  too 
bland  in  character,  e.g.,  when  large  quantities  of  tea,  red 
wines,  and  starches  are  consumed. 

The  effects  of  constipation  are  very  varied.  The  absorp- 
tion of  gases  formed  by  the  fermentative  and  putrefactive 
changes  in  the  fasces  causes  headache,  vertigo,  disorders  of 
vision  and  hearing,  feelings  of  lassitude,  and,  in  many  instances, 
profound  depression  and  gloom.  Such  patients  are  tormented 
by  constant  forebodings  of  ill;  their  aspect  is  dejected,  com- 
plexion muddy,  tongue  furred,  breath  heavy,  appetite  and 
digestion  bad;  and  they  are  often  neuralgic. 


184  Insomnia  and  its   Therapeutics. 

If  the  fasces  are  allowed  to  accumulate  for  weeks  or  even 
months,  the  noxious  materials  absorbed  by  the  blood  cause 
very  pronounced  symptoms,  chiefly  referred  to  the  nervous 
centres.  There  is  generally,  although  not  necessarily,  an  in- 
crease of  temperature;  quick  pulse,  at  times  irregular;  per- 
sistent vomiting;  emaciation  and  prostration.  There  may  be 
cough,  palpitation,  and  liquid  diarrhrea ;  in  short,  many  of  the 
symptoms  resembling  those  of  enteric  fever.  In  all  cases  sleep 
is  interfered  with,  dreams  and  nightmare  being  concomitants 
of  the  milder  cases. 

The  chief  causes  of  disturbed  sleep  are  increased  arterial 
tension  and  hyperagmia  of  the  brain.  This  is  brought  about 
mainly  through  the  centres  in  the  medulla,  and  activity  is  thus 
maintained  in  the  cerebral  cells.  The  implication  of  the 
medullary  centres  is  well  seen  in  the  night  sweats  which  so 
frequently  occur  in  these  cases. 

In  children  constipation  gives  rise  to  very  marked  disturb- 
ance. During  the  day  they  are  peevish,  irritable,  and  easily 
tired,  suffer  from  colicky  pains  in  the  abdomen,  which  cause 
them  to  cry,  often  to  shriek  with  pain,  this  being  associated 
with  flatulent  distention.  Periodic  crying  in  children  is  in- 
variably suggestive  of  intestinal  derangement.  The  bowels, 
in  some  cases,  act  daily,  but  the  quantity  passed  is  insufficient. 
They  eat  fitfully  and  digest  badly,  look  pale  and  sallow,  and 
lose  flesh  quickly.  At  night  they  sleep  badly  and  may  be 
feverish ;  they  wake  up  screaming  as  if  in  pain,  but  they  are 
not  confused  as  in  night-terrors.  They  dream  and  are  rest- 
less, in  the  morning  are  tired  and  weary. 

Treatment. — Sleeplessness  from  this  cause  yields  only  to 
the  removal  of  the  constipation;  a  purgative  will,  in  a  child, 
often  suffice  to  render  sleep  calm  and  healthful. 

It  is  important  to  cultivate  the  habit  of  unloading  the 
bowel  daily  at  a  regular  hour.  All  errors  in  the  ingesta  must 
be  remedied,  and  a  regimen  something  like  the  following 
adopted.  Fruit  should  be  eaten  every  morning  when  dressing. 
Ripe  fruit  in  season,  oranges  in  winter,  or  French  plums  or 
figs,  soaked  the  evening  before  in  a  saucerful  of  cold  water. 
After  the  fruit,  a  claret  glassful  of  hot  water  may  be  slowly 
sipped.  Whole  flour  bread  should  be  preferred  to  white ;  oat- 
meal porridge  with  treacle  or  cream  is  useful  at  breakfast. 
Green  vegetables  and  fruit  should  be  liberally  used  at  luncheon 


Insomnia  and  its   Therapeutics..  185 

and  dinner.  Red  wines,  beer,  brandy,  tea,  milk,  egg's,  cheese, 
nuts,  pastry  and  farinacious  milky  puddings  should  be  avoided. 
A  large  glassful  of  hot  water  should  be  sipped  at  bedtime. 

When  the  defect  is  due  to  enervation,  hot  compresses  ap- 
plied over  the  abdomen  are  often  useful  by  exciting  intestinal 
movements.  Electricity,  either  the  galvanic  or  faradic  cur- 
rents should  be  tried  when  the  muscular  movements  are  weak. 
Baths  of  various  kind  should  be  employed,  followed  by  vigor- 
ous flesh-brushing.  Exercise  in  the  open  air  short  of  fatigue 
should  be  taken.  Horse  exercise  is  the  best. 

Until  these  hygienic  measures  have  time  to  act,  it  is  usu- 
ally necessary  to  prescribe  some  laxative.  Various  mineral 
waters  taken  in  the  morning  fasting  are  useful,  and  may  be 
continued  for  some  time.  Probably  the  best  are  Friedrichs- 
hall,  Hun3radi  Janos,  JEsculap,  and  Rubinat-Condal.  They 
should  be  taken  mixed  with  hot  water,  and  sipped  slowlj'. 

What  answers  equally  well,  and  in  some  cases  better,  being 
less  depressing  in  its  action,  is  an  infusion  of  senna  pods.  It 
is  one  of  the  mildest  and  most  reliable  evacuants  we  possess. 
It  acts  as  a  tonic,  cleaning  the  tongue,  promoting  the  appetite 
and  digestion,  and  increasing  the  muscular  movements  of  the 
whole  alimentary  tract.  It  does  not  cause  griping,  flatulence, 
or  congestion  of  the  pelvic  vessels  like  that  made  from  senna 
leaves.  From  six  to  twelve  pods,  or,  more,  should  be  infused 
in  a  claret  glassful  of  cold  water  for  six  hours,  and  the  infusion 
taken  at  bedtime.  It  is  devoid  of  disagreeable  smell  and 
taste. 

The  following  mixture  and  pills  have  been  found  useful : 

5  Tinct.  nucis  vom., 3  ij- 

Acid.  nit.  dil.,  3  ij. 

Ext.  cascar.  sag., fl.    3  iij. 

Infus.  gentian., ad  §  vi. 

M.  Sig.  Take  a  tablespoonful  in  water  after  meals  twice 
or  thrice  daily. 

5  Aloin., gr.  i. 

Ferri  sulph., gr.  i. 

Ext.  nucis  vom., gr.  ss. 

Pulv.  myrrh., gr.  iss. 

Ext.  hyos.,        . gr.  i. 

Ft.  pil.  i.     Sig.  Take  at  dinner  time. 


1 86  Insomnia  and  its   Therapeutics. 

Or,  if  iron  be  contra-indicated, 

1J  Ext.  aloes  soc., gr.  iss. 

Ext.  nucis  vom.,       ...        .  .  .  gr.  ss. 

Sulph.  quin.,      .        .        ...  .  .  gr.  i. 

Pulv.  capsic.,     .        ...        .  .  .  gr.  i. 

Ext.  gentian.,  .                         .        .  .  .  q.  s. 
Ft.  pil.  i.     Sig.  Take  one  before  dinner. 

When  the  secretions  are  defective,  one  or  other  of  the  fol- 
lowing will  be  found  serviceable  : 

5  Res.  podoph.,    .......  gr.  \. 

Ext.  bell  ad.,      .        .....        .        .  gr.  \. 

Pulv.  ipecac.,    .        .        .        .        .        .        .  gr.  ss. 

Fei.  bov.  inspis.,       .        ,        .        .        .        .  gr.  ij. 
Ft.  pil.  i.    Sig.  Take  one  in  the  evening. 
Or, 

5  Aloin.,       ........  gr.  i. 

Ext.  nucis  vom., gr.  ss. 

Pil.  hydrarg.,    .    *    .  ,        .        .        .  gr.  i. 

Pulv.  ipecac.,    . gr.  ss. 

Fel.  bov.  inspis., gr.  ij. 

Ft.  pil.  i.    Sig.  Take  after  dinner. 

In  all  cases  of  disturbed  sleep  due  to  constipation,  hyoscya- 
mus  is  a  most  useful  remedy,  for  besides  acting  as  a  hypnotic 
in  medium  doses,  it  augments  the  peristaltic  movements  of 
the  intestines. 

When  there  is  any  tendency  to  bleeding  piles,  this  powder 
is  a  reliable  laxative. 

R  Sulphur,  precip., 

Pulv.  cubeb.,      .        .        .        ...        .      aa  3  i. 

Pulv.  guaiac., 3  ij. 

Pulv.  pip.  nig.,  .        .        .        .        .        .     3  i. 

M.  ft.  pulv.    Sig.  A  teaspconf ul  in  water,  night  and  morning. 

In  cases  in  which  the  administration  of  purgatives  appears 
to  still  further  disturb  sleep,  as  in  some  neurasthenic  and 
hypochondriacal  states,  from  two  or  six  minims  of  the  oil  of 
chamomile  flowers  alleviates  the  hyper-sensitivity. 

In  children,  sodium  phosphate  in  unsalted  soup  is  a  pleasant 
if  an  old-fashioned  laxative.  Here  also  is  a  good  and  useful 
prescription.  Take  of  figs,  as  new  and  soft  as  they  can  be 


Insomnia  and  its   Therapeutics,  187 

got,  3  viij.,  powdered  Alexandrian  senna,  3  i.,  treacle  3  ij.  Cut 
the  hard  ends  off  the  figs,  then  cut  them  into  shreds,  add  the 
senna  and  treacle,  and  beat  the  whole  into  a  pulp.  It  is  pleas- 
ant to  taste,  and  the  dose  is  a  piece  about  the  size  of  a  hazelnut. 
Sleep  may  likewise  be  disturbed  by  catarrhal  and  inflam- 
matory affections  of  the  gastro-intestinal  canal,  as  in  diarrhoea 
and  dysentery,  either  acute  or  chronic.  The  treatment  is  ob- 
viousty  that  of  the  disease.  This  remark  is  equally  true  of 
the  wakefulness  of  collapse,  the  result  of  perforation;  as  also 
that  which  occasionally  accompanies  peritonitis;  and  the 
wakefulness  which  is  said  to  attend  cholera  morbus. 


INTESTINAL  WORMS. 
(Ta?nia  solium ;  Ascaris  lumbricoides ;  Oxyuris  vermicularis.) 

Although  these  differ  very  greatly  from  one  another,  the 
symptoms  they  instigate  in  the  nervous  and  alimentary  sys- 
tems are  so  much  alike  that  it  is  convenient  to  discuss  them 
together. 

They  may  be  present  without  giving  rise  to  any  symptoms 
at  all;  or  they  may  reflexly  give  rise  to  diseases  of  the  ner- 
vous system,  such  as  chorea,  etc.  They  invariably  cause  di- 
gestive and  nutritive  derangements;  frequently  sleep  disturb- 
ance and  dreams;  and  occasionally  they  may  excite  night- 
mare, night  terrors,  and  somnambulism.  Grinding  the  teeth 
is  a  common  symptom,  and  if  it  be  not  due  to  gout,  which  is 
rarely  the  case  in  children,  it  should  always  suggest  worms. 
This  source  of  sleeplessness  must  not  be  overlooked,  as  an 
anthelmintic  is  the  only  hypnotic.  Worms  occasionally 
cause  extreme  irritability  of  the  bladder. 

The  general  symptoms  are  capricious  or  perverted  appe- 
tite, pain  and  uneasiness  in  the  abdomen,  itching  of  the  nose 
and  anus,  malaise  associated  with  restlessness,  headache, 
mental  depression,  noises  in  the  ears,  etc.  The  amount  of 
sleeplessness  and  emaciation  that  threadworms  sometimes 
cause  in  adults  is  very  great  indeed.  In  children,  the  reflex 
irritation  which  worms  excite  in  the  bladder  is  occasionally 
so  great  as  to  suggest  disease  in  the  urinary  organs.  This 
may  disturb  sleep. 

Treatment. — This  consists,  of  course,  in  the  expulsion  of 
the  worms. 


CHAPTER  X. 

INSOMNIA  DEPENDING  UPON  AFFECTIONS  OF  THE 

LIVER. 

FUNCTIONAL  DISORDERS  OF  THE  LIVER. 

THE  liver  exerts  an  important  influence  upon  the  digestive 
processes  as  well  as  upon  nutrition.  Its  functions  are  mani- 
fold. It  forms  bile  in  quantities  bearing  a  distinct  relation  to 
the  ingesta ;  a  large  quantity  being  secreted  when  the  food  is 
highly  nitrogenous,  and  a  smaller  amount  when  it  is  oleagin- 
ous. The  liver  also  is  instrumental  in  the  construction  of 
glycogen,  and  in  its  accumulation  until  its  consumption  is  re- 
quired in  the  economy.  It  is  the  organ  which  presides  over 
the  transformation  of  a  certain  proportion  of  the  nitrogenous 
products  into  blood-corpuscles,  and  also  of  the  disintegration 
of  effete  blood-corpuscles;  it  is  concerned  also  in  the  forma- 
tion of  urea. 

Dr.  Lauder  Brunton  credits  the  liver  with  the  power  of  de- 
stroying certain  poisons,  and  of  preventing  their  entrance  into 
the  circulation  in  deleterious  quantities. 

In  the  course  of  the  metamorphosis  of  the  proteids  into 
peptones  (especially  in  the  later  stages),  in  the  small  intes- 
tines, leucin  and  tyrosin  are  formed  as  the  result,  probably,  of 
the  ensuing  decomposition.  These,  in  passing  through  the 
liver,  are  changed  into  uric  acid  and  urea,  and  the  latter,  being 
highly  soluble,  is  excreted  by  the  kidneys.  It  occasionally 
happens,  either  from  inherited  inadequacy  of  the  liver,  or  from 
functional  derangements  induced  by  improper  alimentation, 
that  these  products  are  not  transformed  into  urea,  and  the 
process  being  perverted,  uric  acid  is  formed  in  excess.  Uric 
acid,  being  an  exceedingly  insoluble  substance,  is  excreted  by 
the  kidney  with  great  difficulty.  This  incomplete  metabol- 
ism may  lead  to  lithiasis  and  gout. 

The  liver  being  intimately  concerned  with  the  formation 


Insomnia  and  its   Therapeutics.  189 

and  depuration  of  the  blood,  all  interference  with  its  functions 
implies  derangement  of  sanguinification,  which  necessarily 
affects  the  digestive  processes. 

Functional  derangements  of  the  liver  chiefly  arise  from  the 
secretion  of  bile  being  excessive  or  deficient  in  quantity,  or 
abnormal  in  quality ;  or  they  may  depend  upon  the  imperfect 
completion  of  the  metabolic  processes,  producing  lithsemia,  a 
condition  invariably  attended  by  sleeplessness.  Attention 
was  called  to  this  condition  in  1874  by  the  late  Dr.  Murchison, 
to  whom  we  are  indebted  for  a  great  part  of  our  knowledge 
of  the  subject.  In  discussing  the  symptoms  he  dilated  at  some 
length  upon  the  sleeplessness  that  invariably  accompanies  it, 
and  his  words  are  so  full  of  truth  that  they  are  here  quoted. 
"Sleeplessness  may,  of  course,  arise  from  many  different 
causes,  but  one  of  its  causes  is  that  derangement  of  the  liver 
which  produces  lithasmia.  When  this  is  the  case,  the  patient 
is  often  heavy  and  drowsy  after  a  full  meal,  and  he  may  fall 
asleep  at  once  on  retiring  to  rest ;  but,  after  one,  two,  three, 
or  four  hours,  he  awakes,  and  then  he  either  lies  awake  for 
hours,  or  he  is  constantly  falling  asleep,  dreaming  or  having 
the  nightmare  and  awaking — four  or  five  times  or  even  oftener 
in  the  course  of  one  hour — until  the  morning  comes,  when  he 
drops  into  a  quiet  sleep  of  an  hour  or  more,  or  he  is  obliged  to 
get  up  tired  and  irritable.  This  sleeplessness,  like  the  vertigo 
we  have  already  considered,  is  often  induced  by  particular 
articles  of  diet,  or  by  some  unwholesome  combination  of  them. 
What  will  excite  headache,  giddiness,  or  disorders  of  the  cir- 
culation in  some  patients,  will  in  another  cause  sleeplessness. 
Sometimes,  however,  this  symptom  will  occur  when  the  patient 
is  most  careful  as  to  diet.  What  is  important  also  to  note  is, 
that  in  most  of  these  cases  there  are  no  obvious  symptoms  of 
gastric  dyspepsia;  the  appetite  may  be  good — too  good,  in 
fact;  the  bowels  may  be  regular;  and  there  may  be  no  pain, 
flatulence,  or  other  discomfort  after  meals;  but  there  will  be 
found  an  unusual  tendency  to  the  deposit  of  lithates  in  the  urine, 
and  very  often  other  phenomena  of  a  so-called  gouty  diathe- 
sis. This  form  of  sleeplessness  was  described  a  century  ago 
by  Cullen,  the  distinguished  nosologist,  in  these  words :  '  Per- 
sons who  labor  under  a  weakness  of  the  stomach,  as  I  have 
done  for  a  great  number  of  years  past,  know  that  certain 
foods,  without  their  being  conscious  of  it,  prevent  sleeping. 


19°'  Insomnia  and  its   Therapeutics. 

So  I  have  been  awakened  a  hundred  times  at  two  o'clock  in 
the  morning"  when  I  did  not  feel  any  particular  impression; 
but  I  knew  that  I  had  been  awaked  by  an  irregular  operation 
in  that  organ,  and  I  have  then  recollected  what  I  took  at 
dinner,  which  was  the  cause  of  it.  Dr.  Haller  is  liable  to  the 
same  complaint;  and  in  his  larg-er  work  especially,  he  gives 
the  particulars  of  his  own  case/  " 

The  cause  of  this  sleeplessness  is  irritabilitj"  in  the  cerebral 
cells  more  or  less  pronounced,  brought  about  by  imperfect 
depuration  of  the  blood.  This  excitability  initiates  sleepless- 
ness in  consequence  of  the  perception  of  stimuli  so  slight  as 
not  to  be  otherwise  apparent.  In  this  respect  it  resembles 
that  which  pertains  to  intestinal  dyspepsia.  Sleeplessness  is 
due  also  to  an  increased  blood-pressure.  A  minority  of  the 
sufferers  from  lithaemia  complain  of  no  other  discomfort,  but 
the  origin  of  their  insomnia  can  be  recognized  by  two  signs 
which  are  invariably  present :  increased  vascular  tension,  red 
lithates  in  the  urine.  The  majority  of  such  patients  present 
many  well-marked  symptoms.  The  aspect  is  dull  and  jaded; 
the  complexion  muddy,  sallow,  or  slightly  jaundiced;  and  the 
conjunctivas  tinged  with  bile  pigment.  The  tongue  may  be 
clean,  but  usually  it  is  large,  sodden,  teeth-indented,  and  cov- 
ered with  a  thick  creamy  fur;  the  mouth  in  the  morning  has 
a  bitter  and  disagreeable  taste,  which  may  disappear  in  the 
course  of  the  day.  The  breath  is  often  heavy  and  offensive; 
the  appetite  is  variable,  in  some  cases  it  is  good,  in  others  it 
is  capricious  or  bad,  the  want  of  appetite  being  often  associ- 
ated with  -nausea  and  even  vomiting.  The  bowels  are  slug- 
gish and  the  motions  pale;  haemorrhoids  are  frequent.  The 
urine  is  scanty,  high-colored,  acid,  of  high  specific  gravity,  and 
deposits  urates  on  cooling.  Patients  complain  of  pain  in  the 
head,  giddiness,  and  uncertainty  in  movements;  noises  in  the 
head;  dimness  of  vision,  or  of  motes  floating  before  the  eyes. 
They  suffer  from  palpitation  and  intermission  of  the  heart; 
breathlessness  and  a  sickening  sense  of  oppression  which 
awakes  them  during  the  night;  pain  and  weight  in  the  epi- 
gastric and  right  hypochondriac  regions,  as  also  about  the 
right,  or  it  may  be  the  left,  shoulder.  They  are  often  troubled 
with  flatulence  and  acidity;  oppression,  discomfort,  and  drow- 
siness after  meals,  followed  in  an  hour  or  two  by  feelings  of 
irritability,  lassitude,  and  mental  depression.  Whether  this 


•    Insomnia  and  its   Therapeutics.  191 

depression  is  due  to  the  absorption  of  the  products  of  diges- 
tion, or  to  leucomaines  which  are  formed  in  the  processes  of 
digestion,  is  still  a  matter  of  doubt.  Dr.  Lauder  Brunton, 
who  has  studied  the  subject  with  great  care,  attributes  it  to 
the  depressing  action  of  a  poison  upon  the  nervous  system. 

When  these  marked  symptoms  exist  there  is  no  difficulty 
in  accounting  for  the  sleeplessness. 

The  subjects  of  these  disorders  are  peculiarly  liable  to  suffer 
from  acute  hepatic  dyspepsia  or  attacks  of  biliousness  from 
slight  indiscretions  in  eating  and  drinking.  These  attacks  are 
usually  accompanied  by  catarrhal  conditions  of  the  mucous 
membrane  of  the  stomach  and  duodenum,  and  characterized 
by  headache  and  vomiting.  They  resemble  in  some  respects 
attacks  of  migraine,  for  which  they  are  occasionally  mistaken. 

Treatment, — This  obviously  entails  that  the  liver  must  be 
relieved  of  work  which  it  cannot  overtake,  or,  in  other  words, 
that  its  work  should  be  proportioned  to  its  strength.  The 
food  should  be  poor  in  albuminoid  elements,  that  the  metabolic 
processes  can  be  completely  effected,  and  the  storage  of  effete 
materials  in  the  system  prevented.  This  subject  will  be  con- 
sidered in  detail  under  the  heading  of  gout,  to  which  disease 
it  is  so  closely  related. 

Alcohol  must  be  interdicted  to  a  very  large  extent,  if  not 
altogether,  tending  as  it  does  to  embarrass  the  liver  still 
further.  When  it  is  allowed  it  should  be  in  the  form  of  brandy 
or  whiskey,  well  diluted  with  an  alkaline  effervescing  water; 
malt  liquors  and  sweet  wines  being  inadmissible.  Exercise  in 
the  open  air  is  imperative,  oxygen  being  required  for  the  ade- 
quate performance  of  the  metabolic  changes,  and  horse  exer- 
cise is  the  best  of  all.  Turkish  baths  are  also  to  be  strongly 
recommended.  Sipping  hot  water  night  and  morning  is  a 
powerful  stimulant  of  the  hepatic  functions. 

Mercury  in  the  form  of  calomel,  blue  pill,  or  gray  powder 
must  be  given  until  the  tongue  cleans.  Mercury  was  long 
ago  advised  by  the  late  Dr.  Graves,  and  it  has  gained  the  ap- 
proval of  many  very  able  physicians  in  more  recent  years. 

5  Subchlor.  hydrarg., gr.  ss. 

Pulv.  ipecac.,        .        .        .        .        .        .    gr.  ss. 

Ext.  taraxac., gr.  i. 

Ft.  pil.  i.  Sig.  Take  at  night,  and  in  the  morning,  while 
yet  fasting,  a  dose  of  one  of  the  natural  saline  waters. 


192  Insomnia  and  its   Therapeutics. 

After  the  tongue  has  lost  its  coating,  the  activity  of  the 
liver  should  be  maintained  by  a  pill  containing-  either  leptan- 
drin,  iridin,  euonymin,  or  podophyllin  combined  with  aloin. 

The  increased  vascular  tension  may  be  treated  with  the 
following  mixture : 

B.  lodid.  potass., .        .        .        .     .   .        .        .    3  i. 

Bicarb,  potass., 3  iij. 

Tinct.  aconit.  (B.  P.), TH,  xxiv. 

Tinct.  hydrast., .     3  vi. 

Aq.  chlorof., ad  3  vi. 

M.  Sig.  Take  a  tablespoonful  three  times  a  day,  between 
meals,  in  water. 

Sodium  salicylate  in  10  to  30  gr.  doses,  ammonium  chloride 
in  20-grain  doses,  and  sanguinarin  in  £-grain  doses,  are  useful 
remedies. 

External  applications,  as  hot  poultices  at  bedtime,  or  com- 
presses of  dilute  nitro-muriatic  acid,  in  the  proportion  of  3  i.  to 
§  ij.  of  tepid  water,  over  the  right  hypochondriac  region,  for 
eight  or  ten  nights,  are  usually  beneficial. 

If  sleeplessness  is  very  pronounced  an  alkaline  draught  with 
hops  may  be  given  at  bedtime.  The  writer  has  got  excellent 
results  from  sulphonal  in  20-grain  doses  two  hours  before  bed- 
time ;  and  also  from  methylal  in  doses  ranging  from  tq,  xv.  to 
TTI,  xxx.  When  the  patient  awakes  and  becomes  restless  and 
watchful,  a  teaspoonful  of  Carlsbad  salts,  taken  with  a  tea- 
spoonful  of  syrup  of  ginger  in  a  good  draught  of  water,  has 
the  almost  constant  effect  of  inducing  the  speedy  return  of 
quiet  sleep.  A  like  draught  at  bedtime  frequently  prevents 
wakefulness. 

Hyoscyamus  is  likewise  useful.  Equal  parts  of  the  tinc- 
ture, and  tincture  of  hops  in  teaspoonful  doses  is  a  good  for- 
mula. Opiates,  chloral  hydrate,  etc.,  invariably  do  harm, 
any  sleep  which  they  induce  being  followed  by  an  aggravation 
of  the  symptoms  by  deranging  the  secretions.  Such  remedies 
are  to  be  avoided. 

JAUNDICE. 

Drowsiness  is  the  usual  accompaniment  of  jaundice,  but 
every  now  and  again  the  reverse  condition  is  met  with.  The 
late  Dr.  Graves,  of  Dublin,  wrote  that  "in  jaundice  every- 


Insomnia  and  its   Therapeutics.  193 

thing-  denoting-  an  unusual  state  of  the  nervous  system, 
whether  it  be  too  much  sleep  or  too  little,  demands  your  at- 
tention." He  likewise  pointed  out  that  the  sleeplessness  which 
sometimes  occurred,  manifested  itself  at  the  time  that  the 
jaundice  was  declining-  and  the  bile  beginning-  to  reappear  in 
the  stools. 

Sleeplessness  in  this  disease  commonly  depends  upon  dys- 
peptic derangements,  some  of  which  we  have  already  consid- 
ered, and  also  upon  general  itching-  of  the  skin,  caused  by  the 
circulation  through  it  of  blood  laden  with  bile  acids.  In  re- 
g-ard  to  the  latter,  the  Dublin  physician  called  attention  to 
the  fact,  which  has  since  been  frequently  confirmed  by  others, 
that  the  itching-  sometimes  precedes  the  appearance  of  the 
jaundice. 

Treatment. — When  the  insomnia  is  due  to  dyspeptic  de- 
rangements these  must  be  treated  upon  the  principles  indi- 
cated elsewhere.  When  it  is  due  to  itching-,  the  free  use  of 
alkaline  baths  and  the  flesh-brush  is  useful.  The  following 
lotion  is  serviceable : 

IJ   Bibor.  sodii,       .        .        .        .        .        .        .     §  i. 

Acid,  carbol.  pur., 3  ij. 

Spt.  vini  rect., 1  ij. 

Aquam, ad  f  xxiv. 

M.     Sig-.  Sponge  the  body  as  often  as  required. 

Amylene  hydrate  is  said  to  be  an  efficacious  remedy.  The 
subcutaneous  injection  of  pilocarpkie,  as  recommended  by  Dr. 
Goodhart  and  others,  affords  good  results. 

Where,  in  spite  of  these  remedies,  the  sleeplessness  persists, 
the  hypodermic  injection  of  morphine  combined  with  atropine 
must  be  resorted  to. 

Sleeplessness  occurs  in  connection  with  many  other  diseases 
of  the  liver,  such  as  congestion  and  cirrhosis,  affections  which 
are  most  frequently  induced  by  improper  ingesta;  the  sleep 
disturbance  they  inaugurate  is  therefore  considered  under 
other  headings.  It  is  also  occasioned  by  neuralgic  ailments 
and  gall  stones,  in  which  it  is  obviously  due  to  the  pain  they 
cause. 

It  has  long  been  noted  in  hepatitis.  Dr.  Johnston,  writing 
in  1818,  remarks  that  "disturbed  sleep  and  frightful  dreams 
accompany  and  precede  this  disease  in  almost  every  case." 


194  Insomnia  and  its  Therapeutics. 

Ziemssen  says  that  in  suppurative  hepatitis  sleep  is  disturbed 
by  dreams,  and  frequently  there  is  more  or  less  insomnia,  and 
that  the  latter  "  is  considered  by  medical  observers  in  hot  cli- 
mates to  be  a  characteristic  symptom  of  the  disease  not  to  be 
accounted  for  by  the  physical  suffering-  or  mental  perturbation 
of  the  invalid." 

It  may  be  that  this  persistent  insomnia  is  due  to  the  con- 
tinuously maintained  high  temperature  which  characterizes 
this  disease. 

The  discussion  of  these  diseases  is  obviously  beyond  the 
scope  of  this  work. 


CHAPTER  XL 

GOUT,   ITS   SYMPTOMS  AND  TREATMENT;    WITH  SPECIAL 
REFERENCE  TO  INSOMNIA. 

THIS  disease  is  a  fruitful,  although  not  generally  recognized, 
source  of  insomnia.  It  seems  convenient  to  consider  it  here. 

No  disease  has  been  studied  with  more  persistent  care,  and 
yet  its  pathogeny  is  still  subjudice. 

That  it  depends  upon  the  presence  of  uric  acid  in  excess  in 
the  blood  is  definitely  known.  Sir  A.  B.  Garrod,  who  demon- 
strated its  presence  by  means  of  his  widely-known  thread  ex- 
periment, maintains  that  this  excess  is  a  constant  accompani- 
ment of  acute  and  chronic  gout.  There  are,  however,  many 
contending  opinions  as  to  the  causes  of  its  retention  and  de- 
fective excretion.  It  is  impossible  to  attempt  any  discussion 
of  these  moot  points  in  these  pages;  the  remarks  concerning 
them  will  be  limited  to  those  essential  to  the  elucidation  of 
insomnia. 

The  late  Dr.  Murchison  believed  the  presence  of  uric  acid 
to  depend  upon  defective  liver  function,  giving  rise  to  disor- 
dered metabolism.  He  averred  that  the  normal  processes  by 
which  the  nitrogenous  elements  of  the  food  were  converted 
into  urea,  a  soluble  and  easily  excreted  substance,  became  per- 
verted so  that  uric  acid  was  formed  in  excess;  and  that  acid, 
being  highly  insoluble  and  difficult  to  excrete,  was  retained  in 
the  blood.  To  this  theory  it  was  always  objected  that  gout 
was  not  the  same  disease  as  lithaemia,  and  Dr.  Bristowe  put 
it  tersely  when  he  wrote  that  Murchison  "would  naturally 
consider  gout  to  have  some  such  relationship  to  the  liver  as 
ureemic  dropsy  has  to  the  kidney." 

Garrod  ascribes  the  retention  of  uric  acid  in  the  blood  to 
an  inadequacy  of  the  kidney  to  excrete  it.  He  points  out  also 
that  in  gout  the  sodium  urate  is  deposited  painlessly  in  the 
joints.  Acute  gout  follows  the  deposition,  and  does  not  cause 


196  Insomnia  and  its  Therapeutics. 

it.  On  the  contrary,  he  believes  an  attack  of  acute  gout  is  an 
attempt  to  get  rid  of  the  uric  acid. 

Dr.  Ord  has  given  expression  to  a  theory  which  must 
always  command  thoughtful  consideration.  He  considers  that 
the  deposition  of  sodium  urate  can  only  take  place  in  joints  in 
which  the  tissues  have  previously  undergone  alteration  in 
structure,  and  he  credits  the  nervous  system  with  part  of  the 
faulty  state. 

Gout  has  been  attributed  to  the  nervous  system  by  many 
observers,  and  among  them  by  Cullen.  Sir  Dyce  Duckworth, 
Dr.  Ralfe,  and  others,  believe  that  a  special  centre  for  gout 
exists  in  the  nervous  system. 

The  excess  of  uric  acid  is  therefore  attributed  to  an  exces- 
sive formation  in  the  liver;  to  a  defective  excretion  by  the 
kidney,  due  either  to  the  kidney  itself  or  to  a  condition  of  the 
blood  unfavorable  for  its  elimination ;  and  to  some  abnormal 
state  of  the  nervous  structures. 

A  great  impetus  was  given  to  the  study  of  insomnia  in 
gout  by  the  writings  of  Duckworth  and  Murchison  in  1873  and 
1874.  The  latter  stated  (p.  687)  that  the  dyspeptic  symptoms 
which  disturbed  sleep  were  not  associated  with  any  obvious 
digestive  derangements.  They  both  pointed  out  how  prone 
slight  indiscretions  in  eating  and  drinking  were  to  interrupt 
sleep.  The  question  naturally  arises,  Why  should  sleep  be  so 
easily  disturbed  in  the  gouty  ?  The  writer  believes  that  it 
depends  primarily  upon  mal-nutrition  of  the  cerebral  cells, 
which  renders  them  irritable  and  impressionable.  The  clini- 
cal study  of  gouty  conditions  goes  far  in  the  direction  of  sub- 
stantiating this  proposition. 

The  excess  of  uric  acid  in  the  blood  varies  from  time  to 
time.  It  is  greater,  according  to  Garrod,  previous  to,  and 
during  the  early  days  of,  an  attack  of  acute  gout,  and  it  is 
considerably  less  at  its  height  and  during  defervescence.  It 
probably  varies  in  like  manner  in  the  course  of  chronic  gout. 
Coincident  with  these  varying  quantities  of  uric  acid  in  the 
blood,  the  excretion  is  decreased  and  increased  in  like  ratio. 
It  is  decreased  before  the  onset,  and  at  the  beginning,  of  the 
acute  seizure,  and  it  is  increased  toward  its  termination.  The 
elimination  of  uric  acid  varies  considerably  at  different  parts 
of  the  day.  Dr.  Haig  has  shown  ("Wood's  Med.  and  Surg. 
Monographs,"  "Vol.  V.,  No.  2)  that  it  is  increased  after  the  in- 


Insomnia  and  its  Therapeutics.  197 

gestion  of  food,  and  he  believes  it  to  accumulate  during-  sleep. 
The  alkalinity  of  the  blood  is  decreased  in  gout.  Garrod  has 
recorded  that  it  is  almost  neutral. 

The  products  of  cerebral  activity  or  waste  are  acid.  Dr. 
Lauder  Brunton  has  suggested  that  alkalinity  of  the  blood  is 
an  important  factor  in  the  removal  of  these  acid  products.  It 
seems  to  follow  that  blood,  only  slightly  alkaline,  is  peculiarly 
unsuitable  for  the  depurative  process.  Cells  imperfectly  de- 
prived of  their  detritus  do  not  appear  to  take  up  oxygen 
readily,  and  consequently  they  cannot  be  adequately  nour- 
ished. Hence,  they  grow  excitable  and  hyper-perceptive,  and 
so  responsive  to  faint  impressions.  Eventually  they  assume 
a  state  allied  to  that  met  with  in  neurasthenia.  It  is  before 
the  onset,  and  during  the  first  days  of,  a  paroxysm  of  acute 
gout,  that  the  symptoms  of  mal-nutrition  of  the  nervous  sys- 
tem are  most  marked.  They  vary  from  time  to  time  in  the 
course  of  chronic  gout.  They  correspond  to  the  periods  when 
the  blood  is  known  to  be  most  surcharged  with  uric  acid,  and 
to  be  least  alkaline. 

The  evidence  of  malnutrition  of  the  nervous  system  is 
abundant.  During  the  day  it  is  evinced  by  the  patient  in 
moodiness  and  depression  of  spirits,  sometimes  amounting 
almost  to  hypochondriasis.  At  all  times  testy,  he  is  apt  to 
lose  his  temper  from  trivial  causes.  He  is  restless  and  fidgety. 
At  night  his  sleep  is  liable  to  be  disturbed  and  dream-laden. 
He  often  grinds  his  teeth  during  his  slumbers.  When  sleep  is 
interrupted  his  heart  is  usually  palpitating — indicative  of  per- 
turbed cardiac  centres.  In  the  morning  he  has  a  headache, 
indicating  an  altered  cerebral  condition.  He  suffers  from 
fugitive  pains  in  various  parts  of  the  body.  Sir  James  Paget 
pointed  out  that  gout  mainly  affects  the  sensory  portions  of 
the  nervous  system.  Eventually,  it  is  not  uncommon  to  find 
the  patient  presenting  all  the  symptoms  described  under  the 
head  of  neurasthenia.  If  such  a  patient  comes  under  treat- 
ment for  the  first  time  the  gouty  origin  is  very  apt  to  be  over- 
looked. 

It  has  been  suggested  that  uric  acid  acts  directly  upon  the 
cerebral  cells,  and  if  this  be  the  case  the  depuration  of  the 
products  of  waste  might  be  an  equally  difficult  matter.  The 
writer  believes  the  lessened  alkalinity  of  the  blood  to  be  the 
important  cause.  Some  confirmation  of  this  view  was  lately 


198  Insomnia  and  its   Therapeutics. 

gained  from  the  observations  of  Ehrlich,  to  which  Lauder 
Brunton  called  attention.  Brunton  writes : 

"  You  will  remember  that  the  gray  substance  of  the  brain 
is  possessed  of  a  great  power  of  reduction,  as  shown  by  the 
readiness  with  which  it  reduces  aniline  colors  after  death;  but 
during  life  the  necessity  for  oxygen  is  so  great  that  it  retains 
within  it  a  sufficient  quantity  of  stored-up  oxygen  to  prevent 
such  reduction  taking  place  under  ordinary  circumstances. 
But  if  its  functional  activity  be  augmented  by  stimulation,  its 
store  of  oxygen  is  used  up,  and  thus  it  becomes  ready  at  once 
to  reduce.  Its  very  activity,  however,  gives  rise  to  the  forma- 
tion of  acid  products,  which  lessen  its  reducing  power,  so  that 
the  mere  supply  of  fresh  oxygen  would  not  be  sufficient  to  re- 
store it  to  its  previous  condition  unless  the  acid  were  neutral- 
ized. Arterial  blood  supplies  both  these  requirements,  neu- 
tralizing the  acid  and  giving  off  oxygen  to  the  brain  cells/' 

From  these  data  we  may  conclude  that  the  presence  of 
acid  products  in  the  cerebral  cells  alters  in  some  respect  their 
constitution.  We  can  also  comprehend  the  explanation  of 
the  persistence  of  gouty  insomnia  during  months  or  years,  in 
spite  of  the  use  of  hypnotics;  and,  on  the  other  hand,  why  it 
yields  to  the  use  of  remedies  which  augment  the  excretion  of 
uric  acid. 

Insomnia  may,  however,  depend  to  some  extent  upon  an 
increased  arterial  tension.  In  the  early  stages  of  the  gouty 
habit  this  is  frequently  increased,  as  it  is  in  most  cases  of  dis- 
ordered metabolism.  At  first  it  is  not  constant,  and  it  may 
vary  considerably,  probably  with  the  quantity  of  uric  acid 
retained  in  the  system.  This  would  well  explain  the  different 
qualities  of  sleep  in  the  same  persons  at  different  times.  In 
the  later  stages  arterial  tension  is  dependent  upon  changes  in 
the  blood-vessels  of  an  organic  nature,  and  this  is  associated 
with  sleeplessness  of  a  more  persistent  and  constant  kind. 

It  seems  to  the  writer  that  if  centres  for  gout  are  eventu- 
ally found  to  exist  in  the  medulla  oblongata,  the  frequency 
with  which  circulatory  derangements  interfere  with  sleep  will 
be  even  more  easily  explained.  In  this  connection  it  is  worthy 
of  mention  that  glycosuria — a  symptom  of  gout — can  be  in- 
duced artificially  by  puncture  of  the  vaso-motor  centres. 
Landois  and  Stirling  write:  "When  the  vaso-motor  nerves, 
which  proceed  from  this  centre  to  the  liver,  are  cut  or  par- 


Insomnia  and  its  Therapeutics.  199 

atyzed  in  any  part  of  their  course,  mellituria  or  glycosuria  is 
produced." 

It  may  be  asked  why  sleeplessness  does  not  uniformly 
affect  all  gouty  persons,  instead  of  some  more  than  others. 
Duckworth  gives  an  excellent  answer  to  such  a  question: 
"  Many  sufferers  have  no  troubles  connected  with  the  sleeping- 
state,  just  as  many  have  no  urinary  difficulties,  no  hemicrania, 
and  no  tophi."  A  still  further  answer  will  probably  be  found 
in  this,  that  it  is  chiefly  those  possessing-  cerebral  cells  con- 
genitally  defective  in  stamina  who  suffer  most  severely  from 
sleep  disturbance.  In  gout,  as  in  fevers,  those  sleep  best  who 
have  "strong"  nervous  systems.  The  rule,  to  which  there 
are  few  exceptions,  must  be  remembered,  that  diseases  expend 
themselves  for  the  most  part  upon  the  most  vulnerable  tex- 
tures. Irregular  gout  is  usually  met  with  in  the  lean  neurotic, 
who  from  his  temperament  is  peculiarly  liable  to  sleeplessness. 
Moreover,  in  such  cases  the  true  origin  of  the  insomnia  may 
be  unrecognized. 

ACUTE  GOUT. 

Paroxysms  of  sthenic  gout  are  met  with  most  frequently 
in  males  of  sanguine  temperament.  Increased  restlessness 
and  irritability  by  day  and  sleeplessness  by  night  are  common 
premonitory  symptoms.  When  the  paroxysm  supervenes, 
sleep  is  prevented  by  pain  and  by  febrile  sj-mptoms.  A  quick- 
ened pulse  and  an  increased  temperature  are  constantly  pres- 
ent. The  onset  usually  takes  place  during  sleep  between 
two  and  five  in  the  morning;  under  favorable  circumstances 
the  pain  yields,  and  sleep  returns  toward  morning.  In  the 
evening  the  pain  and  febrile  symptoms  recur  with  such  sever- 
ity as  to  prevent  sleep,  and  these  nocturnal  exacerbations  dis- 
turb sleep  during  several  successive  nights. 

Treatment. — The  treatment  of  this  form  of  insomnia  is 
that  of  gout  itself.  Colchicum  is  the  remedy  for  gouty  pain; 
it  should  be  given  with  sodium  salicylate  internally,  in  doses 
suited  to  the  individual  patient.  Opiates  are  best  avoided. 
Garrod  remarks:  "  Cullen  thus  answers  the  question:  'Opi- 
ates give  the  most  certain  relief  from  pain,  yet  when  given  in 
the  beginning  of  a  gouty  paroxysm  they  cause  it  to  return 
with  greater  violence.'  .  .  .  My  own  experience  has  led  me  to 
form  a  very  similar  opinion,  and  in  the  majority  of  gouty 


2OO  Insomnia  and  its  Therapeutics. 

cases,  unless  the  pain  be  very  excessive,  or  there  be  fear  that 
if  not  relieved  the  patient's  nervous  system  will  suffer,  I  always 
feel  disposed  to  withhold  their  administration,  and  trust  to 
other  means,  as  opiates  tend  so  powerfully  to  diminish  the 
secretions  and  to  augment  congestion  of  the  portal  system." 
Chloral  and  like  hypnotics  are  useless,  as  they  do  not  influence 
pain. 

Externally,  soothing  applications  afford  some  relief.  Opium, 
belladonna,  and  lithium  citrate  with  morphine  are  all  useful. 
In  some  cases  tincture  of  iodine  alleviates  the  pain. 

IRREGULAR  GOUT. 

It  is  chiefly  to  irregular  gout  that  we  wish  to  refer.  This 
'is  most  obscure  in  its  nature.  It  seems  quite  certain  that 
uric  acid  can  give  rise  to  disease  in  almost  every  texture  of 
the  body,  without  being  deposited  in  them,  or  without  giving 
rise  to  any  of  the  ordinary  or  usual  manifestations  of  gout. 
Indeed,  the  most  extensive  organic  changes  may  supervene, 
and  proceed  to  a  fatal  termination,  so  insidiously  and  pain- 
lessly that  they  may  fail  to  attract  the  notice  of  the  victim  or 
his  friends. 

The  symptoms  of  irregular  gout  are  obscure  and  ill-defined, 
and  they  vary  considerably  with  the  textures  they  implicate. 
There  are  two  symptoms,  however,  which  are  seldom  absent, 
even  in  the  most  vague  instances;  these  are,  an  increased 
vascular  tension  and  sleep  disturbance.  When  these  occur  in 
conjunction  one  with  another  they  afford  a  valuable  clue  to 
the  line  of  investigation. 

We  must  briefty  survey  the  usual  symptoms  of  chronic  or 
irregular  gout  as  they  affect  the  various  systems. 

.  The  Nervous  System. — This  is  variously  affected.  Head- 
ache, vertigo,  and  migraine  are  by  no  means  uncommon. 
Noises  in  the  head,  often  very  pronounced  and  distressing; 
troublesome  throbbing  of  the  arteries  of  the  head,  most  no- 
ticed when  the  head  is  placed  upon  the  pillow;  irritation  of 
the  optic  nerve,  as  evidenced  by  dimness  of  vision  and  scintilla- 
tions; sleeplessness;  restlessness,  or  fidgets,  are  generally 
present.  Neuralgia  is  of  frequent  occurrence,  and  usually 
takes  the  form  of  facial  or  cervico-brachial  neuralgia,  lumbago 
or  sciatica.  Such  neuralgias,  which  often  come  on  during 


Insomnia  and  its  Therapeutics.  201 

sleep,  are  associated  with  increased  blood -pressure,  and  are 
only  relieved  by  anti-gouty  remedies.  Flitting  pains,  occur- 
ring1 in  various  fascia? — pains  which  are  often  designated  rheu- 
matic— are  frequently  of  gouty  origin.  They  are  more  likely 
to  be  gouty  when  they  follow  the  ingestion  of  wine  or  beer. 
Cramps  in  the  limbs  are  common  symptoms.  They  usually 
obcur  during  the  state  of  transition  from  waking  to  sleeping. 
If  they  come  on  during  sleep  they  interrupt  it.  They  most 
frequently  supervene  before  the  onset  of  an  acute  paroxysm — 
at  the  time  when  the  blood  is  surcharged  with  uric  acid ;  just 
as  the3T  are  prone  to  follow  excessive  muscular  fatigue,  when 
the  blood  is  laden  with  the  acid  products  of  muscle  waste. 
They  are  not,  however,  of  much  diagnostic  value,  as  they  occur 
in  many  persons  suffering  from  anaemia,  cachexia,  neurasthe- 
nia, and  dyspepsia. 

All  gouty  affections  have  a  predisposition  to  make  their 
appearance  during  sleep.  Apoplexy  is  sometimes  the  imme- 
diate cause  of  death.  Cerebral  mischief  always  portends  evil. 
The  throbbing  blood-vessels,  tinnitus,  and  painful  affections, 
are  all  inimical  to  sleep. 

Alimentary  System. — Gout  initiates  many  derangements; 
amongst  others,  acidity,  flatulence,  heartburn,  gastralgia, 
nausea  and  vomiting,  and  irregularity  and  constipation  of  the 
bowels,  with  a  tendency  to  haemorrhoids.  Gastric  disorders,  so 
slight  as  to  be  characterized  by  no  manifest  symptoms,  may 
give  rise  to  sleep  disturbance.  This-  is  specially  true  of  those 
arising  from  trivial  indiscretions  in  eating  and  drinking,  and 
from  the  ingestion  of  food  to  which  some  gouty  persons  are 
intolerant.  The  sleeplessness  of  gout  resembles  that  of  hepa- 
tic dyspepsia  in  this  respect,  but  it  differs  from  it  in  not  always 
arising  from  such  causes.  Flatulent  distention  of  the  stomach 
and  intestines,  by  emb  rrassing  the  respiratory  and  cardiac 
movements,  frequently  causes  terrifying  dreams,  nightmare, 
and  disturbed  sleep.  Tympanites  in  advanced  cases  is  a  dis- 
tressing and  occasionally  fatal  complication. 

Spasmodic  dysphagia  may  occur.  In  a  case  under  ob- 
servation for  many  years  it  alternated  with  gouty  eczema. 
Gouty  conditions  of  the  mucous  membrane  of  the  pharynx  are 
common. 

The  Liver. — Derangements  of  the  liver  are  necessarily  fre- 
quent, and  enter  into  the  causation  of  the  affection.  The 


2O2  Insomnia  and  its   Therapeutics. 

functional  ailments  which  have  already  been  discussed  are  apt 
to  cause  eatarrhal  and  congestive  affections  of  the  liver  and 
its  ducts,  which  eventually  lead  to  indurated  and  cirrhotic 
forms  of  disease. 

Circulatory  System. — At  first  there  are  no  organic  changes. 
Palpitation,  breath lessness,  irregularity  of  the  pulse,  increased 
blood-pressure,  and  accentuation  of  the  second  cardiac  sound 
in  the  aortic  area,  alone  exist.  Changes,  commencing  in  the 
kidneys,  etc.,  produce  thickening  of  the  muscular  coats  of  the 
arteries,  which  thickening  increases  until  the  vessels  become 
atheromatous  and  tortuous,  when  they  pulsate  visibty,  and 
feel  like  a  cord  under  the  finger.  The  heart,  particularly  the 
left  side,  hypertrophies,  and  its  impulse  becomes  forcible  and 
heaving.  Eventually  failing,  hypertrophy  interferes  with  the 
compensation,  and  the  coronary  arteries  degenerating,  origin- 
ate retrograde  changes  in  the  muscular  structures  of  the 
heart,  the  impulse  grows  feeble,  and  dyspnrea  on  exertion  be- 
comes very  marked.  The  aorta,  becoming  atheromatous,  may 
give  rise  to  aneurism.  Attacks  of  angina  pectoris  are  of  fre- 
quent occurrence.  In  the  early  stages,  arterial  tension  pre- 
vents the  hardened  cerebral  arteries  from  contracting  their 
lumen  to  lessen  the  blood-supply  when  the  hour  for  sleeping 
comes  round,  and  as  cerebral  activity  is  maintained,  the  night 
is  spent  in  watching. 

In  the  later  stages  the  lumen  of  the  blood-vessels  may  be 
so  narrowed  by  degenerative  changes  that  the  cerebral  sub- 
stance is  even  more  imperfectly  nourished,  and  sleeplessness 
in  such  cases  may  be  due  to  cerebral  anasmia.  The  nutrition 
of  the  brain  is  still  further  interfered  with  by  the  quality  of 
the  blood;  the  corpuscles,  or  oxygen-carriers,  it  contains  being 
greatly  diminished.  If  the  patient  gets  to  sleep,  the  effects 
of  the  circulation  of  deficiently-oxidized  and  imperfectly- 
depurated  blood  through  the  cardiac,  vaso-motor,  and  respira- 
tory centres  in  the  medulla  must  not  be  overlooked.  These 
centres  are  working  at  their  lowest  level,  and  are  liable  to  be 
affected  by  such  conditions;  hence  the  nocturnal  attacks  of 
palpitation  and  dyspnoea  which  so  often  occur.  The  late  Dr. 
Milner  Fothergill,  referring  to  this  point,  wrote :  "  They  may 
be  due  to  spasm  of  the  pulmonary  capillaries,  or  more  proba- 
bly, to  the  disturbing  effect  of  the  waste-laden  blood  upon  the 
respiratory  centres.  In  sleep  the  respiratory  centre  acts  less 


Insomnia  and  its   Therapeutics.  203 

energetical!}7  than  in  the  waking1  state — is  to  some  extent  de- 
pressed, in  other  words;  and  the  waste-laden  blood  probably 
further  depresses  it,  till  an  attack  of  dyspnoea  is  the  result." 
The  miseiy  endured  by  a  patient  suffering  from  an  enlarged 
heart,  atheromatous  vessels,  and  an  abnormal  blood-current, 
is  occasionally  very  great.  In  the  evening  he  nods  in  his 
chair,  and  is  quite  worn  out  with  sleep ;  whenever  he  lies  down 
in  bed  he  becomes  wide  awake,  and  lies  counting  hour  after 
hour;  if  he  dozes,  it  is  to  wake  up  in  a  start,  arid  toward 
morning1,  when  quite  exhausted,  he  may  get  two  or  three 
hours'  sleep.  This  morning  sleep  seems,  in  most  cases,  to 
depend  upon  the  lowering  of  the  circulation  which  takes  place 
at  that  hour. 

The  veins  are  frequently  the  seat  of  inflammatory  changes, 
and  the  pain  these  affections  cause  interferes  with  sleep. 

Respiratory  System. — The  circulation  of  blood  (possessing- 
qualities  just  detailed)  through  the  respiratory  centres  brings 
in  its  train  asthmatic  attacks,  and  these  are  more  frequent 
during  the  night.  It  initiates  catarrhal  conditions  of  the 
mucous  membrane  of  the  nose,  throat,  and  bronchial  tubes, 
and  it  often  gives  rise  to  bronchitis.  In  the  later  stages  the 
lesions  of  the  heart  may  secondarily  cause  pneumonic  consoli- 
dation as  well  as  pleurisy  and  hydrothorax. 

Urinary  System. — Reference  has  already  been  made  to  the 
condition  of  the  kidney.  The  constant  circulation  through  it 
of  blood  surcharged  with  uric  acid  leads  to  irritation  of  its 
structures,  and  eventually  to  cirrhosis.  In  the  early  days  of 
the  irritative  stage  the  urine  may  be  of  high  specific  gravity, 
of  deep  color,  laden  with  pink  urates  which  deposit  on  cooling, 
or  with  crystals  of  uric  acid.  As  the  disease  advances,  inter- 
stitial changes  in  the  kidneys  progress,  until  eventually  the 
cortical  substance  is  practically  destroyed,  while  concurrently 
the  heart  and  arteries  are  implicated  and  the  vascular  pressure 
is.  greatly  augmented.  The  urine,  as  a  consequence,  is  in- 
creased in  quantity,  and  may  be  quite  clear  and  even  pale. 
The  solids  may  not  be  diminished,  for  the  urea  per  ounce,  mul- 
tiplied by  the  number  of  ounces  passed,  shows  that  an  almost 
normal  amount  is  excreted  in  twenty-four  hours.  This  is  not 
always  the  case.  The  writer,  for  example,  has  long  had  under 
observation  a  patient  who,  during  the  past  two  years,  has  not 
excreted  more  than  two  hundred  and  fifty  grains  of  urea  in 


204  Insomnia  and  its   Therapeutics. 

any  twenty-four  hours,  and  the  amount  has  occasionally  not 
exceeded  one  hundred  and  fifty  grains.  Yet  this  patient  lives 
her  life  fairly  well,  suffering*  almost  no  discomfort,  and  the 
most  pronounced  complaint  is  of  disturbed  nights.  It  seems 
probable  from  this  and  similar  cases  that  many  persons,  the 
subjects  of  gouty  kidneys,  can,  on  careful  diet  and  regimen, 
exist  for  long  periods,  excreting-  urea  in  much  smaller  quanti- 
ties than  are  supposed  to  be  normal.  Albumin  in  faint  traces 
may  appear  in  the  urine  from  time  to  time,  and  tube-casts 
also,  hyaline  and  granular.  They  require,  however,  to  be 
carefully  searched  for,  and  their  detection  is  by  no  means  es- 
sential to  the  diagnosis.  Dropsy  is  rare,  usually  not  amount- 
ing to  more  than  oedema  of  the  conjunct! vee,  of  the  eyelids,  or 
to  a  fulness  of  the  ankles  toward  night.  Frequent  micturi- 
tion is  usually  present  throughout  the  whole  course  of  the 
disease.  Much  light  is  thrown  upon  such  cases  by  the  oph- 
thalmoscope, as  albuminuric  retinitis  is  present  in  many  in- 
stances. The  habitual  use  of  this  instrument  is  not  to  be 
omitted  in  connection  with  obstinate  cases  of  insomnia. 

Goutj*-  glycosuria,  depending  upon  impairment  of  the  liver, 
and  upon  an  inability  to  store  up  glycogen,  by  setting  up  vul- 
var  pruritus,  interferes  with  sleep.  Pruritus  vulvas  and  ec- 
zema of  the  prepuce  should  always  suggest  sugar  in  the  urine, 
or,  at  least,  gouty  disease. 

Integumentary. — Uric  acid  in  the  blood  appears  to  give 
rise  to  marked  irritation  in  the  skin.  Sir  Charles  Scudamore 
wrote:  "And  a  distressing  itching,  particularly  affecting  the 
back  and  arms,  is  very  much  complained  of  by  those  who  are 
liable  to  gout.  It  not  unusually  occurs  as  one  of  the  premoni- 
tory S3Tmptoms.  An  erythematous  rash,  and  urticaria,  or 
nettle-rash,  also  occur;  and  in  one  remarkable  instance  I  saw 
the  latter  irritation  exist  in  a  violent  degree,  during  two  days 
before  the  paroxysm;  to  which,  and  the  treatment  adopted, 
it  immediate]}'  3rielded."  Erythema  intertrigo  under  the 
breasts,  in  the  groins,  and  round  the  genitals  is,  in  some  cases, 
most  troublesome,  as  the  itching  it  causes  always  grows 
worse  at  night,  and  prevents  and  disturbs  sleep.  Eczema, 
too,  is  a  common  symptom.  It  is  usually  bilateral.  The  less 
acute  forms  are  often  persistent,  and  difficult  to  cure.  The 
active  varieties  are  intractable,  and  prone  to  interfere  with 
sleep.  The  violent  paroxysms  of  itching  to  which  they  give 


Insomnia  and  its   Therapeutics.  205 

rise  not  only  interrupt  sleep,  but  they  prevent  its  return. 
The  exhaustion  which  such  seizures  induce,  combined  with  the 
loss  of  sleep,  may  imperil  life.  They  certainly  aggravate  the 
affection.  General  itching-  of  the  skin  and  pruritus  ani  are 
frequently  present,  and  interfere  with  sleep. 

There  is  a  class  of  gouty  patients  who,  although  not  suffer- 
ing from  any  of  these  pronounced  abnormal  cutaneous  condi- 
tions, have  harsh  and  dry  skins — skins  that  do  not  easily  per- 
spire. These  persons  are  unusually  prone  to  sleep  disturbance 
and  asthmatic  seizures,  and  relief  from  these  symptoms  is  sel- 
dom obtained  until  the  skin  becomes  softer,  and  assumes 
healthier  functions. 

Tophi  in  the  ear  are  the  source  of  annoyance  from  the  pain 
they  cause  when  the  head  is  laid  on  the  pillow. 

Patients  suffering  from  gout  are  almost  constantly  dis- 
turbed with  burning  sensations  in  the  palms  of  the  hands  and 
the  soles  of  the  feet;  the  skin  of  the  former  being  often  very 
red  and  tender.  A  patient  observed  upon  one  occasion  that 
he  could  sleep  quite  well  if  he  had  no  hands  or  feet. 

Swelling  of  the  subcutaneous  tissue  is  sometimes  the  source 
of  discomfort,  and  is  chiefly  seen  in  the  back  and  haunches. 

In  cases  where  any  or  most  of  the  foregoing  symptoms 
are  pronounced,  no  difficulty  in  the  diagnosis  presents  itself. 
When,  however,  sleeplessness  is  the  only  symptom,  care  is  re- 
quired to  trace  it  to  its  true  source.  The  history  of  the  sleep 
habit  is  always  helpful.  It  closely  resembles  that  described 
by  Dr.  Murchison,  which  is  quoted  under  the  heading  of  hepa- 
tic dyspepsia  (page  687).  The  patient  usually  gets  to  sleep 
quickly  after  going  to  bed,  to  awake  at  two  or  three  A.M.,  and 
to  remain  wakeful  for  hours,  usually  falling-  asleep  again  an 
hour  or  two  before  the  time  for  rising.  He  gets  up  worn  out 
and  dejected,  indeed  more  tired  than  when  he  went  to  bed. 
Generally  he  suffers  no  discomfort  during  his  wakefulness, 
but  at  times  he  is  afflicted  with  fidgets,  and  occasionally  with 
restlessness  so  considerable  that  he  is  compelled  to  rise  and 
wander  about.  The  sleeplessness  is  increased  by  all  indis- 
cretions in  eating  and  drinking.  As  a  rule,  such  patients  sleep 
better  in  summer  and  in  warm  climates  than  in  winter  and  in 
cold  regions,  provided  always  that  the  heat  is  not  excessive. 
The  warmth  appears  to  promote  sleep  by  relaxing  the  vascu- 
lar tension. 


206  Insomnia  and  its   TJierapeutics. 

The  diagnosis  rests  mainly  upon  the  general  symptoms  of 
gout,  particularly  upon  the  condition  of  the  vascular  tension 
and  of  the  urine.  The  teeth  sometimes  afford  a  clue,  those 
well-enamelled  being  frequently  seen  in  the  gouty,  while  in 
some  cases  they  are  worn  away  by  constant  friction,  from  the 
grinding  of  the  teeth  both  by  day  and  night  that  is  so  charac- 
teristic of  the  disease.  The  liability  to  cramps  in  the  limbs 
and  to  flushings  of  the  body,  and  to  burnings  of  the  palms  of 
the  hands  and  the  soles  of  the  feet,  are  all  indicative  of  gout. 
The  occurrence  of  gouty  nodes  on  the  fingers,  or  of  nails 
striated  longitudinally,  throws  much  light  upon  a  case.  The 
physiognomy  of  gouty  persons  so  ably  depicted  by  Lay  cock 
is  worthy  of  careful  study.  The  origin  of  some  very  obscure 
cases  may  be  rendered  clear  if  they  quickly  yield  to  anti-gouty 
treatment.  This,  although  an  unsatisfactory  line  of  diagnosis, 
has  the  sanction  of  high  authority.  It  is  a  clumsy  method, 
and  one  which  a  physician  should  avoid,  as  every  surgeon  does 
the  use  of  an  exploring  needle  in  the  diagnosis  of  deep-seated 
suppuration.  With  care  it  should  be  unnecessary. 

Causes  of  Gout. — These  are  so  numerous  that  we  can  only 
refer  to  a  few  of  them.  First  must  be  placed  the  predisposing 
cause  of  heredity.  Garrod  estimates  it  in  hospital  patients  at 
50  per  cent,  and  in  private  cases  at  75  per  cent.  Heredity 
does  not  throw  any  light  upon  the  source  of  gout,  as  an  in- 
adequate liver,  inadequate  kidneys,  a  tendency  to  degenera- 
tion in  certain  structures,  leading  to  the  deposition  of  urate 
salts,  as  well  as  disordered  centres  for  gout,  are  each  and  all 
capable  of  being  transmitted  hereditarily.  They  are  likewise 
capable  of  being  originated  anew,  and  of  being  transmitted  to 
the  offspring.  Males,  probably  on  account  of  their  habits  and 
mode  of  living,  are  more  subject  to  it  than  females.  In  women 
it  seldom  shows  itself  before  the  menopause,  and  its  develop- 
ment then  is  the  source  of  much  of  the  insomnia  which  attends 
that  epoch. 

The  absence  of  a  distinct  history  must  not  be  too  much 
relied  upon.  The  symptoms  and  signs  of  gout  must  be  inter- 
preted without  such  a  guide.  The  following  will  illustrate  a 
not  infrequent  experience.  The  writer,  early  in  his  career, 
was  consulted  by  a  lady  advanced  in  years,  whose  life  was 
rendered  unbearable  by  sleeplessness,  her  only  other  symptom 
being  an  occasional  attack  of  migraine.  Examination  dis- 


Insomnia  and  its  Therapeutics.  207 

closed  the  fact  that  she  was  suffering1  from  high  arterial  ten- 
sion, and  the  opinion  given  was,  that  she  was  the  subject  of 
irregular  gout.  There  was  not,  so  far  as  could  be  discovered, 
any  history  of  gout,  but  that  meant  only  that  no  ancestor 
had  been  pronounced  gouty.  Abstemious  and  frugal  in  her 
habits  to  the  last  degree,  and  active  physically,  she  had  lived 
a  life  that  was  not  calculated  to  have  created  the  disease 
anew.  The  diagnosis  admitted  of  no  uncertainty,  and  that 
the  gout  was  hereditary  the  writer  never  doubted.  She  died 
eight  years  afterward  of  ursemic  symptoms  from  cirrhotic 
kidneys,  and  during  these  years  the  gradual  diminution  of 
urea  and  uric  acid  excreted  was  noted,  coincidently  with  grow- 
ing changes  in  the  heart  and  blood-vessels.  At  the  same  time 
the  manifestations  of  irregular  gout  were  observed  in  her 
grown-up  family.  Her  eldest  child  died  at  the  menopause 
from  cirrhotic  kidneys  with  the  usual  complications;  the 
second  is  now,  and  has  been  for  many  years,  the  subject  of 
gouty  glycosuria;  the  third  maintains  a  moderate  amount  of 
health  by  frequently  visiting  German  spas;  while  the  fourth 
has  tophi  in  his  ear,  and  suffers  from  gouty  irregularity  of  the 
heart. 

It  may  be  caused  de.  novo  by  the  use  of  foods,  in  quantity 
or  quality,  such  as  throw  an  unusual  tax  upon  the  liver,  or 
which,  by  producing  congestion  in  that  organ,  impair  its  func- 
tional activity.  These  aliments  may  be  summed  up  respec- 
tively as  large  quantities  of  albuminoid,  oleaginous,  and  sac- 
charine substances;  and  excessive  quantities  of  spirits,  wines, 
and  malt  liquors.  Gout  may  be  developed  by  a  life  of  luxury 
and  ease,  and  by  the  daily  neglect  of  an  adequate  amount  of 
exercise.  It  is  also  caused  by  deficient  supply  of  oxygen,  in- 
terfering with  the  oxidizing  processes  of  the  liver.  This  may 
be  brought  about  by  living  and  sleeping  in  badly-ventilated 
apartments.  It  may  arise  from  over-fatigue,  depressing  emo- 
tions, great  excitement,  excesses  of  all  kinds  which  debilitate 
the  system,  as  also  from  the  ingestion  of  lead.  It  occurs  more 
commonly  in  damp  cold  weather. 

It  is  met  with  in  every  part  of  the  globe,  but,  according  to 
Hirsch,  it  is  rare  in  the  tropics.  It  has  been  well  recognized 
since  the  days  of  Hippocrates,  and  has  always  followed  in  the 
train  of  luxury,  affluence,  and  self-indulgence.  Hirsch  believes 
it  does  not  now  prevail  to  the  same  extent  that  it  once  did. 


208  Insomnia  and  its   Therapeutics. 

It  exists  in  greater  proportion  in  England  than  in  Scotland 
and  Ireland.  Sir  Charles  Scudamore  in  1817  wrote :  "  In  Scot- 
land, gout  is  much  more  rare  than  in  England.  In  Edin- 
burgh, where  the  habits  of  the  people  approach  the  nearest 
to  those  of  London,  it  is  found  most;  but  it  is  scarcely  ever 
known  among  the  inferior  classes."  ...  "In  Glasgow,  the 
gout  is  very  rare,  even  among  the  higher  classes."  He  attri- 
buted this  to  the  people  drinking  whiskey  and  living  chiefly 
on  farinaceous  and  other  vegetable  diet,  which  he  believed 
initiated  diabetes  and  not  gout. 

The  writer,  however,  is  of  opinion  that  gout  is  not  a  rare 
disease  in  Scotland,  and  he  believes  that  it  has  never  been  so 
rare  as  some  writers  have  supposed.  The  evidence  is  certainly 
conflicting.  When  Sir  Charles  Scudamore  recorded  the  rarity 
of  gout  in  Glasgow,  he  presented  his  work  on  that  subject  to 
an  eminent  physician  in  that  important  centre,  a  work  which 
two  years  ago  (through  the  kindness  of  the  sole  survivor  of 
that  gentleman)  came  into  the  writer's  possession.  It  is 
somewhat  curious  that  many  of  that  physician's  ancestors 
had  suffered  from  gout,  and  that  his  wife  came  from  an  old 
and  honorable  family  who  could  number  many  victims  to  the 
same  disease,  perhaps  exceeding  in  number  the  total  cases 
which  Sir  Charles  believed  to  exist  in  Scotland.  Scudamore 
apparently  forgot  that  Scotland  had  given  London  the  illus- 
trious Hunters,  William  and  John,  both  of  whom  suffered 
from  gout.  It  is  affirmed  that  they  were  abstemious  men, 
and  therefore  were  not  likely  to  develop  the  disease  afresh. 
So  far  from  its  occurring  from  the  accident  of  residence  in 
London,  we  have  the  late  Professor  Laycock's  assurance  that 
their  father  "  had  at  least  one  of  the  diseases  of  the  gouty 
habit,  namely, ( gravel.' "  No  one  who  has  visited  their  birth- 
place in  the  parish  of  East  Kilbride  can  believe  that  luxury 
ever  abounded  there. 

Further,  if  gout  has  been  such  a  rare  disease  in  Scotland, 
it  seems  inexplicable  how  Cullen,  whose  writings  on  gout  are 
still  studied,  though  a  century  has  elapsed  since  he  penned 
them,  should  have  found  cases  for  study,  as  he  never  practised 
except  in  Edinburgh  and  Glasgow.  Notwithstanding  his 
high  position  and  brilliant  fame,  which  must  have  attracted 
to  him  many  of  the  wealthier  classes  from  distant  parts,  it 
seems  reasonable  to  suppose,  that  he  must  necessarily  have 
studied  acute  gout  in  the  people  among  whom  he  lived. 


Insomnia  and  its   Therapeutics.  209 

Again,  it  is  be\*ond  question  that  Laycoek,  than  whom  no 
man  ever  left  his  personality  more  firmly  impressed  upon  the 
literature  of  gouty  disease,  must  necessarily  have  studied  the 
malady  during-  the  last  twenty  years  of  his  life  in  Edinburgh. 

Garrod,  in  discussing  the  influence  of  alcoholic  drinks, 
states,  upon  the  authority  of  Dr.  (afterward  Sir  Robert) 
Christison,  that  cases  of  gout  are  seldom  seen  in  Scotland. 
Against  that  must  be  placed  the  opinion  of  Warburton  Begbie, 
who  had  the  most  ample  opportunities  in  hospital  and  private, 
as  well  as  consulting  practice,  of  accurately  estimating  its 
prevalence,  and  he  distinctly  expressed  his  dissent  by  saying 
he  could  not  confirm  the  statement  that  gout  occurred  very 
rarely.  Still  more  recently  Fothergill  and  Duckworth  have 
expressed  their  opinions  that  gout  is  rare  north  of  the  Tweed. 

Professor  Grainger  Stewart  of  Edinburgh,  in  a  letter  to 
the  writer,  states :  "  My  experience  satisfies  me  that  gout  and 
gouty  disorders  are  of  very  frequent  occurrence  among  the 
wealthier  classes  in  Scotland,  for  I  see  its  manifestations  con- 
stantly in  my  consulting  room,  and  in  cases  to  which  I  am 
called.  But  it  is  rare  among  hospital  patients." 

The  writer,  who  in  Stirlingshire  and  Ayrshire  had  ample 
opportunities  of  studying  disease,  is  in  concord  with  Stewart; 
but  he  would  add  that  gout  is  prevalent  among  the  middle 
classes,  and  that  its  manifestations  are  occasionally  to  be  met 
with  among  the  working  population.  He  is  quite  unable  to 
agree  with  the  opinion  that  diabetes  is  unusually  common  in 
Scotland,  for  he  did  not  meet  with  that  disease  frequently; 
upon  the  other  hand,  he  had  at  one  time,  in  his  own  practice, 
as  many  as  eight  cases  of  gouty  glycosuria  under  observation. 
The  suspicion,  therefore,  arises  that  some  at  least  of  the  cases 
referred  to  by  Scudamore  may  have  been  glycosuric;  hence 
gouty. 

These  cases  are  interesting  from  a  diagnostic  point  of 
view,  as  four  of  the  subjects  came  seeking  advice  for  sleep- 
lessness, three  for  pruritus  vulvas,  and  one  for  eczema  of  the 
prepuce;  in  each  case  the  glycosuria  was  discovered  in  inves- 
tigating the  cause  of  the  symptom. 

This  question  of  gout  in  Scotland  has  been  raised  for  the 
purpose,  mainly,  of  expressing  the  opinion  that  the  use  of 
whiskey  is  not  so  free  from  the  risk  of  engendering  gout  as 
some  suppose. 


2io  Insomnia  and  its   Therapeutics. 

Treatment. — It  goes  without  saying1  that  the  treatment  of 
gouty  insomnia  is  practically  that  of  the  disease  itself.  We 
shall,  therefore,  briefly  indicate  it. 

The  first  aim  must  be  to  remove  from  the  blood  the  excess 
of  the  uric  acid  which  contaminates  it;  and  second,  to  arrange 
the  patient's  life  and  regimen  so  as  to  prevent  its  further  ex- 
cessive formation  and  reaccumulation. 

One  of  the  conditions  responsible  for  the  excess  of  uric  acid 
must  be  held  clearly  in  view — an  impaired  liver;  for  it  is  only 
by  regulating  the  work  imposed  upon  that  organ,  in  accord- 
ance with  its  functional  activity,  that  the  abnormal  formation 
can  be  obviated. 

There  is  an  overwhelming  accumulation  of  evidence  to 
show  that  in  no  disease  is  the  life  and  health  of  an  individual 
so  entirely  in  his  own  hands  as  in  gout.  He  can,  if  he  will,  do 
much  to  procure  immunity  from  his  enemy,  and  to  enjoy  a 
healthy  and  active  life.  The  supplies  must  be  cut  down  to 
the  actual  requirements  of  the  body,  so  that  waste-products 
may  not  be  allowed  to  accumulate.  It  is  specially  necessary 
that  nitrogenous  substances  should  not  be  taken  in  larger- 
quantity  than  is  needed  for  tissue  formation;  while  the  amount 
of  starches,  sugars,  and  fats  consumed  should  be  such  as  can 
be  quickly  and  easily  digested  and  assimilated. 

The  meals  should  be  fixed  at  regular  hours,  and  mastica- 
tion slowly  and  thoroughly  performed.  Late  meals  are  un- 
desirable, the  best  hour  for  dinner  (which  ought  to  be  a  light 
repast)  being  7  o'clock,  and  luncheon  should  constitute  the 
most  substantial  meal  of  the  day.  A  few  general  indications 
may  be  added  as  regards  diet. 

All  meat  should  be  well  kept  and  plainly  cooked,  white 
meat  being  preferred  to  brown.  The  best  forms  are,  mutton 
and  lamb,  lamb's  head  or  calf's  head,  sweetbread  (the  throat 
is  the  best),  tripe,  game,  and  poultry.  Fat  bacon  is  admissi- 
ble at  breakfast.  Beef,  pork,  and  veal  are  best  avoided. 

Soups  (not  too  strong),  such  as  clear,  white,  oyster,  or 
made  with  white  fish,  are  all  good. 

Fish,  as  sole,  turbot,  brill,  halibut,  plaice,  whiting,  or  raw 
oysters,  is  very  suitable. 

Eggs  must  be  eaten  sparingly. 

Milk  and  milky  puddings  (without  eggs)  and  farinaceous 
foods  of  all  kinds. 


Insomnia  and  its   Therapeutics.  21 1 

All  vegetables  (excepting-  rhubarb,  tomatoes,  sorrel,  as- 
paragus, broad-beans,  and  peas),  provided  they  do  not  cause 
flatulence. 

Ripe  fruits,  either  cooked  or  uncooked,  when  they  agree, 
are  excellent. 

Saccharine  and  oleaginous  matters  are  to  be  eaten  spar- 
ingly, tending  as  they  do  to  produce  dyspeptic  disturbance. 

It  is  absolutely  necessary  that  a  quantity  of  fluid  be  taken 
daily,  as  diluents  promote  the  excretion  of  the  solids.  The 
best  of  all  is  pure  water,  and  a  tumblerful  (warm  or  cold) 
should  be  sipped  every  morning  during  dressing,  and  another 
of  Apollinaris  or  seltzer-water  before  bedtime.  Skim  milk 
and  whey  are  good  diluents.  Tea  and  coffee  are  to  be  taken 
sparingly,  as  they  retard  digestion  and,  like  alcohol,  hinder 
tissue-metamorphosis. 

If  the  patient  is  strong  he  should  eschew  alcohol  in  every 
form,  but  when  some  stimulant  is  deemed  advisable,  the 
quantity  should  be  limited  and  taken  with  meals  only.  Malt 
liquors  and  heavy  wines,  as  burgund}^  port,  or  sherry,  must 
be  forbidden.  The  best  forms  are  light  claret,  hock,  sauterne, 
and  well -matured  dry  champagne.  Champagne  disagrees 
with  many  gout3r  persons,  but  it  suits  an  equal  number  better 
than  any  other  wine,  just  as  Amontillado  agrees  with  a  small 
minority;  and  when  experience  dictates  such  a  fact  it  is  not 
to  be  ignored.  Sparkling  hock  is  a  light  and  agreeable  stimu- 
lant, which  suits  many  patients  well.  Whiskey  and  unsweet- 
ened gin  freely  diluted  with  an  alkaline  water  are  admissible. 
Upon  the  ground  that  gout  was  unknown  (?)  in  Scotland,  a 
country  famous  for  the  consumption  of  whiskey,  that  stimu- 
lant has  been  largely  prescribed  in  gouty  cases.  Time  will 
probably  show  that  it  is  not  so  free  from  objection  as  is  sup- 
posed. 

It  remains  to  be  added  that  though  the  great  proportion 
of  gouty  persons  are  best  treated  upon  the  lines  just  indicated, 
there  are  some  who  do  not  get  on  well  upon  such  a  regimen. 
Their  idiosyncrasies  rebel,  and  they  are  better  in  every  way 
upon  food  and  stimulant  restricted  in  quantity  only.  Some 
of  the  most  troublesome  cases  of  irregular  gout  are  met  with 
in  the  most  abstemious  and  in  tea  drinkers.  Many  who  look 
strong  and  plethoric  bear  lowering  treatment  very  badly. 

The  late  Dr.  Parkes,  in  his  work  on  Practical  Hygiene, 


212  Insomnia  and  its   TJierapeutics. 

states  that  the  standard  daily  diet  for  an  adult  man  should 
consist  of — 

Nitrogen,          .  316.5  grains. 

Carbon, 4862. 

Salts, 461. 

and  he  gives  the  following  table,  which  indicates  the  constitu- 
ents of  ordinary  food : 

ONE  OUNCE  (=437.5  grs.)  CONTAINS  IN  ITS 
SUBSTANCE.  NATURAL  STATE  IN  GRAINS  : 


Water.         Nitrogen.        Carbon.      Salts. 

Uncooked  meat  (beef) 328  10.35  64  7 

Uncooked  fat  meat  (beef) 275.6  9.6  98.3  16 

Cooked  meat 236  19  117.7  13 

Bread 175  5.5  119  5.6 

Wheat  flour 65.6  7.6  169  7.4 

Biscuit 35  22.7  183  7.4 

Rice 43.7  3.5  176  2.2 

Oatmeal  (Letheby's  numbers) 65.6  8.7  172  13 

Maize 59  7  176  6 

Peas 65.6  15  161  10 

Potatoes 324  1  49  4.4 

Carrots 398  1.4  18  3 

Butter 26  .2  315  11.8 

Egg 321  9.3  71.5  4.4 

Cheese 161  23  162  23.6 

Milk 380  2.75  30.8  2.6 

Sugar 13  ....  187  2 

The  clothing  should  be  light  and  warm  to  promote  the 
free  action  of  the  skin,  and  to  prevent  the  occurrence  of  chills. 
Exercise  is  probably  par  excellence  the  best  of  all  the  means 
of  treatment^  Bodily  activity  must  therefore  be  enjoined. 
It  is  essential  that  it  be  taken  in  the  open  air,  as  a  plentiful 
supply  of  oxygen  is  needed.  Horse  exercise  is  the  best  of  all, 
as  it  increases  the  functional  activity  of  the  liver,  and  relieves 
plethora  of  the  abdominal  viscera.  Fatigue  and  all  depress- 
ing influences  must  be  avoided.  4 

A  fair  amount  of  mental  work  is  beneficial  to  health,  and 
promotes  sleep.  Overwork,  on  the  contrary,  is  detrimental. 

The  morning  bath  is  best  tepid,  and  soap  should  be  freely 
used,  the  soap  being  of  suitable  quality.  The  Turkish  bath, 
taken  under  medical  advice,  is  of  great  service.  The  sham- 
pooing is  of  special  service. 

A  mild  and  dry  climate  suits  the  gouty  best,  and  it  con- 
duces to  improved  sleep. 

Mineral  waters  have  long  been  sought  after  by  the  gouty, 


Insomnia  and  its   Therapeutics.  213 

and,  conjoined  with  altered  methods  of  living,  such  as  early 
hours,  plain  and  simple  feeding,  with  change  of  air  and  scene, 
they  are  frequently  highly  beneficial.  In  this  country  the 
waters  of  Bath,  Cheltenham,  Harrogate,  Buxton,  Droitvvich, 
Leamington,  Woodhall,  Moffat  and  Strathpeffer  are  chiefly  in 
request.  Abroad,  the  spas  are  without  number,  each  possess- 
ing certain  climatic  advantages,  and  the  waters  differing  in 
constituents  and  temperature.  The  resort  in  each  case  must 
be  selected  with  special  reference  to  these  factors.  Among 
them  may  be  named  Vichy,  Horn  burg,  Carlsbad,  Marienbad, 
Contrexeville,  Kissingen,  Wiesbaden,  and,  when  arthritic 
troubles  are  present,  Aix-les-Bains  and  Luchon. 

General  Medication. — The  emunctories  must  be  kept  in 
an  active  state.  The  skin  has  been  alluded  to,  and  also  the 
kidneys  in  connection  with  the  use  of  diluents.  The  bowels 
should  be  moved  daily. 

To  reduce  arterial  tension  in  the  earlier  stages  of  the  affec- 
tion, and  to  promote  the  excretion  of  uric  acid,  certain  medi- 
cines which  act  upon  the  liver  and  kidneys  are  useful.  Dr. 
Noel  Paton  recently  ascertained  from  his  experiments  upon 
dog's  that  "the  formation  of  urea  in  the  liver  bears  a  very 
direct  relationship  to  the  secretion  of  bile  by  that  organ," 
and  also  "  that  drugs  which  increase  the  quantity  of  bile  in  dogs 
.  .  .  also  increase  the  urea  in  the  urine  "  (Landois  and  Stirling). 
This  is  exactly  in  accordance  with  clinical  experience.  An 
occasional  dose  of  calomel  or  blue  pill  at  night,  followed  in 
the  morning  by  a  dose  of  Friedrichshall,  Piillna,  or  Hunyadi- 
Janos  water,  or  of  sodium  sulphate,  is  always  beneficial.  If, 
for  any  reason,  it  is  desired  to  avoid  mercury,  then  podophyl- 
lin,  euonymin,  leptandrin,  and  iridin  with  coloc3rnth  or  colchi- 
cum  may  be  employed  separately  or  in  combination.  Colchi- 
cum  has  a  very  decided  influence  on  the  excretion  of  urea  and 
uric  acid,  and  no  reliable  evidence  has  yet  been  forthcoming 
that  its  use  is  attended  by  any  bad  effects,  as  has  been  so  fre- 
quently and  popularly  alleged ;  on  the  other  hand,  there  is  a 
large  consensus  of  opinion  as  to  its  utility.  The  following  is 
a  useful  pill  in  persons  who  are  robust: 

3   Pil.  hydrarg., gr.  i. 

Pil.  coloc.  co., gr.  iij. 

Ext.  colchic.  acet., gr.  i. 

Ft.  pil.  i.     Sig.  Take  at  bedtime. 


214  Insomnia  and  its  Therapeutics. 

Sulphur  is  in  many  cases  a  valuable  remedy : 

$  Pulv.  guaiac., 3  v. 

Sulphur,  lact., 3  iij. 

Mel.  dep., 3  vi. 

Pulv.  glycyrr., gr.  xx. 

Ft.  elect.    Take  a  piece  the  size  of  a  hazelnut  at  bedtime. 

The  alkalies,  such  as  the  salts  of  potassium  and  lithium, 
by  entering-  into  combination  with  the  uric  acid,  and  forming- 
soluble  salts,  promote  the  excretion  of  the  acid  The  sodium 
salts  forming  urate  of  soda,  which  is  highly  insoluble,  are  to 
be  avoided.  Potassium  iodide,  and  bicarbonate,  and  sodium 
salicylate  are  useful  remedies,  their  action  being  promoted  by 
free  dilution.  Sal  ammoniac  is  likewise  a  reliable  drug,  pro- 
moting the  excretion  of  solids.  In  dyspeptic  conditions,  alka- 
lies should  be  given  after  meals,  and  the  use  of  alkaline  waters 
during  meals  avoided,  as  likely  to  increase  the  acidity.  The 
following  powder  is  serviceable : 

fy  Bicarb,  potass., 

Garb,  magnes.  pond., 

Garb,  bismuth., aa  3  iij. 

Pulv.  aromat.  co., 3  i. 

M.  Sig.  Take  a  teaspoonful  in  water  after  meals  when 
required. 

When  flatulence  is  troublesome  some  charcoal  or  sulpho- 
carbolate  of  sodium  may  be  added  to  it.  The  following  pill 
is  useful : 

$  Terebinth.  Chiae,        .        .        .        .        .    gr.  iiss. 

Gum.  galban., gr.  iss. 

Pulv.  ipecac., gr.  f . 

Ft.  pil.  i.    Sig.  Take  one  night  and  morning. 

Should  tympanites  be  pronounced,  electricity  (the  continu- 
ous current)  will  often  enable  the  bowel  to  pass  the  flatus  on- 
ward. Quinine  or  Warburg's  tincture,  injected  into  the  bowel, 
are  also  reliable  agents.  An  enema  of  the  infusion  of  rue  is  an 
efficacious  remedy. 

The  cardiac  symptoms  require  attention.  In  the  early 
stages  of  the  disease  tincture  of  aconite  controls  excitement 
and  palpitation,  and  relaxes  vascular  tension.  In  angina 
pectoris  the  nitrites  are  called  for;  they  also  relieve  the  mi- 


Insomnia  and  its  Therapeutics.  215 

graine  and  headache  which  occasionally  prove  troublesome. 
In  the  stage  of  failing1  compensation  of  the  heart  digitalis  and 
ferruginous  tonics  may  be  required,  and  it  is  advantageous  to 
mix  them  with  sal  ammoniac. 

IJ  Hydrochlor.  ammon., 3  iv. 

Tinct.  ferri.  mur.  (Ed.  Ph.),    .        .        .        .  3  iv. 

Tinct.  digital., 3  i. 

Glycerin.,          • §  i. 

Aq.  chlorof ., ad  §  vi. 

M.  Big-.  Take  a  tablespoonful  in  water  thrice  daily  after 
meals. 

Digitalis  must  be  given  cautiously,  as  it  may  precipitate 
an  apoplectic  seizure  by  raising-  still  further  the  blood-pressure. 
Asthmatic  and  bronchitic  attacks  yield  to  ordinary  treatment 
for  gout.  Nocturnal  dyspnoea,  depending-  upon  undue  irrita- 
bility or  impressionability  of  the  respiratory  centres,  is  at 
times  relieved  by  the  following- : 

IJ  Tinct.  belladon., 3  ij. 

Liq.  strychn., 3  i. 

Spt.  ammon.  arom.,         .        .        .        .        .    3  vi. 

Spt.  chlorof., .    3  vi. 

Aquam, ad  §  vi. 

M.  Sig-.  Take  a  tablespoonful  in  water  at  five  P.M.,  at  bed- 
time, and  during-  the  nig-ht  if  required. 

Irritability  of  the  bladder  is  alleviated  by  potassium  bro- 
mide and  henbane. 

Neuralgia  needs  special  as  well  as  g-eneral  treatment; 
local  applications  of  camphor-chloral  or  menthol,  with  the 
internal  administration  of  sal  ammoniac,  afford  good  results 
(p.  637).  Antipyrine  likewise  acts  well,  but  it  has  the  objec- 
tion of  raising  the  blood-pressure.  Many  cases  of  gouty  lum- 
bago yield  to  acupuncture,  and  also  to  dry  cupping,  as  sciatica 
does  to  blistering1,  and  muscular  pains  to  deep  massage.  Mor- 
phine, however,  has  to  be  resorted  to  when  the  pain  is  urgent 
and  severe. 

When  cramps  in  the  limbs  tend  to  recur  at  night,  the 
avoidance  of  excessive  muscular  fatigue  must  be  enjoined.  If 
that  cannot  be  dispensed  with,  a  warm  bath  at  bedtime  and 
a  draught  of  lithium  citrate,  or  potassium  bicarbonate,  with  a 


2i6  Insomnia  and  its   Therapeutics. 

full  dose  of  sumbul  or  camphor,  will  probably  avert  the  seiz- 
ure. Amylene  hydrate  has  been  greatly  lauded  in  this  trou- 
blesome ailment.  It  is  averred  that  cramps  do  not  occur  so 
frequently  in  persons  who  sleep  with  the  head  of  the  bed  well 
raised.  A  high  pillow  is  not  sufficient.  For  immediate  relief 
when  the  cramps  come  on,  nothing-  answers  so  well  and  quickly 
a^s  turning  out  to  stand  upon  a  piece  of  cold  wax-cloth  at  the 
side  of  the  bed. 

Affections  of  the  skin  must  be  sedulously  attended  to,  as 
they  always  disturb  sleep.  General  pruritus  may  be  relieved 
by  warm  alkaline  baths,  or  by  lotions,  as  boracic  acid,  potas- 
sium bromide,  or  carbolic  acid.  A  solution  of  menthol  has 
been  recommended,  but  it  not  rarely  hinders  sleep  by  the  cold 
sensation  it  produces,  as  well  as  by  its  smell  (p.  633). 

In  acute  eczema  every  effort  must  be  made  to  allay  the 
paroxysmal  itching,  and  to  promote  sleep.  The  nightly  ad- 
ministration of  cannabis  indica,  hyoscyamus,  camphor  mono- 
bromide,  or  belladonna,  either  given  alone  or  in  combination, 
will  insure  this.  In  urgent  cases  morphine  may  be  required. 
Diuretics  and  mild  mercurials  must  be  given,  and  if  arsenic 
be  prescribed,  its  effects  should  be  carefully  observed,  as  it 
occasionally  increases  the  distress.  Localty,  the  exposure  of 
the  surfaces  to  the  air  and  frequent  washings  must  be  avoided. 
Dusting  the  parts  with  boracic  acid,  lycopodium,  or  oxide  of 
zinc,  and  protecting  them  with  starch  poultices,  are  suitable 
remedies.  In  the  subacute  cases,  ointments  spread  on  linen 
should  be  carefully  laid  over  the  parts  to  exclude  the  air.  The 
following  have  been  found  useful :  Bismuth  subnitrate,  6  parts; 
zinc  oxide,  1  part;  cerat.  Galeni,  q.s.  to  make  a  soft  ointment; 
zinc  carbonate,  6  parts;  salicylic  acid,  1  part;  cerat.  Galeni,  a 
sufficiency  to  make  an  ointment;  or  boracic  acid  ointment. 
In  chronic  cases  zinc  ointment,  containing  either  carbolic  acid, 
tar  or  ichthyol,  are  suitable.  In  dry  and  chronic  cases  the  itch- 
ing is  quickly  relieved  by  sulphurous  acid. 

Pruritus  ani  must  be  treated  locally  as  well  as  generally; 
sponging  the  parts  with  hot  water  at  bedtime  and  then  ap- 
plying one  or  other  of  the  following  remedies  usually  affords 
relief.  Dusting  with  equal  parts  of  powdered  sulphur  and 
oxide  of  zinc,  or  applying  calomel  ointment  (  3  i.  to  3  i.),  co- 
caine ointment  (10  to  20  per  cent),  black  wash,  carbolic  acid 
lotion  (1  to  100). 


Insomnia  and  its   Therapeutics.  217 

5  Acid,  hydrocy.  (Scheele's),  .  .  .    3ij. 

Sulph.  zinc.,       .        .        .  .  .  .  .     3  ss. 

Oxid.  zinc.,        •'  .     .        .  {  .  .  .     3  ij. 

Glycerin.,         ...       .        .  .  .  .  .     §  i. 

Aq.,    .        .        .        .        .  .  .  .  ad  |  vi. 

M.     Sig.  Apply  at  bedtime. 

When  there  are  small  cracks  or  fissures  in  the  skin  round 
the  anus,  verdigris  ointment  often  answers  admirably.  Mild 
mercurials  with  small  doses  of  sulphur,  as  in  the  above  formulae, 
are  useful  remedies. 

If  the  sensation  of  burning-  in  the  soles  of  the  feet  hinder 
sleep,  it  may,  in  some  instances,  be  relieved  by  an  india-rubber 
bag-  filled  with  cool  or  cold  water,  which  can  be  used  or  dis- 
carded at  pleasure. 

Sleeplessness  will  frequently  yield  to  the  foregoing  regi- 
men, and  require  no  special  treatment.  If  it  does  not,  attention 
must  be  paid  to  the  temperature  of  the  sleeping-  apartment, 
for  if  it  is  a  few  degrees  higher  or  lower  than  the  sitting-room 
it  may  cause  wakefulness. 

Douching1  the  head  with  luke-warm  water,  a  hot  foot-bath, 
a  wet  pack,  or  friction  of  the  body  at  bedtime,  are  all  useful 
aids  to  sleep.  Dr.  Broadbent  has  suggested  lying-  with  the 
back  of  the  neck  on  a  hot  bottle.  It  has,  however,  always 
seemed  doubtful  to  the  writer  whether  such  an  aid  as  this  did 
not  frequently  act  as  a  disturbant.  The  following  has  been 
found  a  useful  remedy  in  the  early  stages. 

#  Tinct.  aconit.  (B.  P.), m  iij. 

Tinct.  belladon., ""I  x. 

Bicarb,  potass., gr.  xx. 

Aqua*  menth.  pip., i  ij. 

M.     Sig.  Take  at  bedtime. 

It  is  also  efficacious  taken  a  few  minutes  after  awaking. 
A  whiff  of  nitrite  of  amyl,  or  a  dose  of  Carlsbad  salts,  are 
both  useful  on  awaking. 

In  severe  cases  it  is  well  to  apply  leeches  to  the  temples, 
and  repeat  them  as  often  as  it  is  necessary.  Chloral  hydrate 
and  paraldehyde  are  the  best  hypnotics.  Opiates  and  mor- 
phine are  always  hurtful. 

In  the  later  stages  the  nitrites  are  the  best  hypnotics :  two 


218  Insomnia  and  its   Therapeutics. 

grains  of  sodium  nitrite  thrice  daily,  with  an  occasional  sniff 
of  amyl  nitrite  during-  the  night,  seldom  fails  to  do  good.  The 
\vriter  has  seen  two  minims  of  a  one-per-cent  solution  of  nitro- 
g-lycerin  given  at  bedtime  induce  sleep  which  lasted  nine 
hours. 


OHAPTEE  XII. 

INSOMNIA  DEPENDING  UPON  AFFECTIONS  OF  THE 
CIRCULATORY  SYSTEM. 

IN  every  case  of  insomnia,  the  causation  of  which  cannot 
be  traced  to  some  disorder  of  the  nervous  or  digestive  sys- 
tems, or  to  derangement  of  the  metabolic  processes,  it  is  nec- 
essary to  inquire  most  narrowly  into  the  state  of  the  heart 
and  blood-vessels ;  for  participating-,  as  they  do,  with  the  nerv- 
ous system  in  the  daily-increasing  wear  and  tear  of  life,  they 
not  infrequently  become  impaired  by  the  strain  they  are  called 
upon  to  bear.  Many  of  the  diseases  that  so  arise  become  the 
sources  of  insomnia. 

Organic  changes  in  the  heart  and  blood-vessels  may  orig- 
inate, and  insidiously  increase,  until  they  develop  into  positive 
and  alarming  lesions,  without  exciting  the  attention  of  the 
victim;  and  it  is  not  until  some  secondary  affection,  such  as 
dyspepsia  or  insomnia,  attracts  his  notice,  that  he  seeks  ad- 
vice. Indeed,  he  comes  on  account  of  symptoms  which  he 
does  not  attribute  to  his  heart,  and  among  which  perturba- 
tion of  sleep  is  one  of  the  most  common  and  significant. 

It  has  been  often  and  truly  said,  that  a  patient  suffering 
from  heart  disease  seldom  seeks  aid  for  it.  On  the  other 
hand,  those  who  ask  counsel  for  symptoms  which  they  deem 
due  to  cardiac  disease,  are  either  the  subjects  of  neurosal  affec- 
tions or  do  not  suffer  from  any  disease  of  the  heart  at  all.  It 
is  indeed  rare  that  a  patient  connects  his  want  of  sleep  with 
his  heart,  unless  he  is  suffering  from  that  very  apparent  and 
distressing  symptom,  palpitation.  Yet,  there  is  scarcely  a 
derangement  of  the  heart,  either  functional  or  organic,  which 
does  not  modify  the  distribution  of  blood  in  the  brain  and 
nervous  system  to  some  extent.  This  altered  blood-supply  is 
almost  invariably  attended  by  disturbed  sleep,  nightmare,  or 
dreaming,  and,  in  some  instances,  by  persistent  insomnia. 


220  Insomnia  and  its   Therapeutics. 

Alterations  in  the  cerebral  circulation  arise  from  causes 
interfering"  with  the  normal  rhythmic  action  of  the  heart,  such 
as  occurs  in  cardiac  excitement ;  from  alterations  in  the  tone 
and  lumen  of  the  arteries,  capillaries,  and  veins,  leading-  to 
modifications  of  blood-pressure  and  to  venous  stasis;  and 
from  variation  in  the  quantity  or  quality  of  the  blood  trans- 
mitted. Such  vascularization  is  inimical  to  sleep,  for  among 
the  conditions  essential  for  good  sleep  are,  a  heart  beating- 
quietly  and  slowly,  and  a  lowered  arterial  tension.  It  is  only 
by  scrutinizing  all  these  points  closely,  and  searching  for 
sig-ns  of  heart  disease,  that  this  source  of  sleeplessness  can  be 
disclosed,  and  its  relief  effected. 

It  is  proposed,  first,  to  briefly  allude  to  the  most  usual 
symptoms  of  heart  disease  which  prevent  sleep,  namely,  pal- 
pitation, dyspnoea,  Cheyne-Stokes'  respiration,  cardialgia,  and 
angina  pectoris;  and  then,  in  a  few  words,  to  refer  to  sleep- 
lessness as  it  occurs  in  some  valvular  diseases,  in  fatty  degen- 
eration of  the  heart,  and  in  aneurism. 

Palpitation. — Among-  the  numerous  symptoms  of  func- 
tional and  organic  affections  of  the  heart,  which  interfere  with 
sleep,  palpitation  holds  the  first  place.  It  may  present  itself 
at  any  hour  during-  the  day  or  night,  either  in  trivial  degree 
or  in  the  most  urg-ent  form ;  in  the  latter,  the  heart  beats  vig- 
orously and  tumultuously,  causing  the  walls  of  the  chest  to 
heave  and  the  larger  blood-vessels  of  the  body  to  throb  and 
pulsate  visibly. 

Palpitation  may  be  a  symptom  of  organic  disease  of  the 
heart,  the  structural  changes  being  commonly  those  of  degen- 
eration, or  hypertrophy  of  the  muscular  walls,  or  dilatation 
of  the  cavities;  or  it  may  be  caused  by  aneurism.  It  appears 
chiefly  after  exertion  when  the  heart  is  coping  with  defective 
conditions  and  quickened  movements,  struggling,  in  short,  in 
its  weakened  state,  to  discharge,  temporarily,  work  more 
laborious  than  usual. 

'  Functional  palpitation  is  met  with  usually  in  younger  per- 
sons, and  is  either  associated  with  hremic  changes,  neurosal 
derang-ements,  or  toxic  causes.  Frequently  it  is  more  severe 
in  character  than  the  organic. 

Palpitation  from  haemic  disorder  depends  upon  two  causes, 
blood  faultily  formed  and  imperfectly  depurated. 

Examples  of  the  former  are  to  be  found  in  those  suffering 


Insomnia  and  its  Therapeutics.  221 

from  anaemia,  chlorosis,  and  from  debility,  however  brought 
about ;  in  which  states  the  quality  of  the  blood  is  impaired, 
and  the  blood  pressure  modified,  the  cardiac  centres  perceiv- 
ing- and  resenting-  quickly  an  imperfectly  oxyg-enated  blood 
circulating-  through  them.  Examples  of  the  latter  are  to  be 
found  in  those  suffering  from  defective  metabolism,  as  in 
gout,  etc. 

The  neurosal  cases  can  usually  be  traced  to  overwork, 
worry,  excesses,  over-excitement  of  the  passions  or  affections, 
hysteria,  or  to  sources  of  reflex  irritation,  e.g.,  dyspepsia  and 
other  derang-ements  of  the  gastro-intestinal  canal,  worms, 
ovarian  or  uterine  disorder,  and  spinal  irritation. 

The  toxic  causes  embrace  the  indiscreet  use  of  tobacco,  tea, 
and  alcohol. 

It  occurs  invariably  in  exophthalmic  g-oitre.  That  which 
supervenes  in  hysterical  patients  (male  or  female)  is  associ- 
ated with  heightened  blood  tension — constriction  of  the  arteri- 
oles — as  evidenced  by  the  copious  secretion  of  colorless  urine. 

The  diagnosis  between  palpitation  depending-  upon  organic 
disease,  and  functional  disorder,  must  rest  largely  upon  the 
presence  or  absence  of  physical  signs  of  org-anic  heart  disease. 
It  is  more  probably  organic  when  the  pulse  is  irregular;  when 
murmurs  indicative  of  valvular  lesions  are  heard;  or  when  the 
heart  is  enlarged.  We  may  conclude  it  is  organic  if  we  find 
any  of  the  common  secondary  effects  of  heart  disease,  such 
as  dropsy,  are  present;  or  that  the  palpitation  and  the  ac- 
companying dyspnrea  are  set  up  and  further  aggravated  by 
exertion;  or  when  we  find  the  attack  is  not  severe,  and  occurs 
only  as  an  exacerbation  of  a  more  permanent  disorder. 

On  the  other  hand,  it  is  more  likely  to  be  functional  when 
the  pulse  is  intermittent;  when  murmurs  are  absent,  or  if 
present,  most  distinctly  heard  at  the  base  and  in  the  large 
vessels  of  the  neck,  their  intensity  being  increased  by  the  erect 
posture;  when  the  heart  is  of  small  size;  when  the  attacks 
are  severe  and  paroxysmal  in  character,  and  when  they  come 
on  during  rest,  and  are  benefited  by  exercise. 

Palpitation,  whether  of  organic  or  functional  origin,  is 
liable  to  prevent  the  onset  of  sleep,  and  to  interrupt  it  when 
it  has  ensued.  In  the  latter  case  severe  attacks,  occurring  at 
distant  intervals  and  traceable  to  some  exciting  cause,  are 
invariably  functional;  while  attacks  less  severe,  recurring  fre- 


222  Insomnia  and  its   Therapeutics. 

quentty  without  apparent  reason,  are  generally  organic  in 
their  genesis. 

The  late  Sir  Thomas  Watson  wrote :  "  I  must  caution  you, 
however,  against  the  mistake  which  is  often  made,  of  infer- 
ring that  the  heart  is  free  from  organic  change  because  its 
irregular  movements  are  accompanied  by  dyspeptic  symp- 
toms. Structural  disease  of  that  organ  is  very  apt  to  derange 
the  digestive  functions.  You  will  commonly  find  that  patients 
who  labor  under  such  disease  are  exceedingly  liable  to  flatu- 
lence of  the  stomach,  and  free  eructation  of  the  gas  which 
plagued  them  mitigates  wonderfully  the  cardiac  distress.  It 
does  so,  no  doubt,  by  relieving  the  diaphragm  from  that  up- 
ward pressure  which  embarrassed  the  motions  of  the  heart." 
..."  The  age,  and  frequently  the  sex,  of  the  patient  form 
leading  points  in  the'  diagnosis.  Nervous  palpitations  are 
apt  to  come  on  when  the  patient  is  quite  at  rest :  palpitations 
that  result  from  organic  disease  are,  on  the  contrar}7,  miti- 
gated, usually,  by  repose.  The  occurrence  of  palpitations  in 
the  night,  however,  is  but  an  equivocal  circumstance,  for  nerv- 
ous persons  who  dream,  awake  often  with  palpitation;  and 
the  recumbent  posture  is  apt  to  excite  or  to  aggravate  the 
palpitations  that  are  organic/' 

Palpitation  may  be  excited  during  sleep  by  tying  on  the 
left  side,  by  large  accumulations  of  flatus  in  the  stomach,  and 
by  all  perturbing  impressions  arising  in  the  economy.  These 
impressions  being  transmitted  to  the  cardiac  centres  in  the 
medulla,  and  then  reflected  through  the  sympathetic  to  the 
heart,  instigate  disorderly  and  excited  movements,  which 
arouse  the  sleeper;  and  the  throbbing  of  the  heart,  and  pulsa- 
tions of  the  vessels,  dyspnoea,  and  feelings  of  oppression,  com- 
bined with  mental  agitation,  prevent  the  recurrence  of  sleep 
for  some  hours. 

The  distress  which  palpitation  causes  is  occasional^  so 
great  as  to  make  the  patient  afraid  to  fall  asleep  again,  lest  it 
should  return.  In  the  majority  of  cases,  it  is  the  hypersemia 
of  the  brain  that  interferes  with  sleep,  hyperaemia  being  in- 
separable from  an  accelerated  action  of  the  heart,  and  an  in- 
creased blood-pressure. 

Treatment. — In  each  and  every  case  the  exciting  cause 
must  be  obviated.  When  it  depends  upon  weakness  of  the 
muscular  walls,  or  upon  dilatation  of  the  cavities  of  the  heart, 


Insomnia  and  its  Therapeutics.  223 

patients  should  be  counselled  to  avoid  exertion  or  strain,  and 
not  to  lie  on  the  left  side.  The  food  should  be  highly  nutritious, 
and  as  concentrated  as  possible;  stimulant  being1  allowed  up 
to  the  limit  of  promoting  the  digestive  processes. 

Digitalis  and  convallaria  majalis  are  the  remedies  most 
called  for. 

I£  Tinct.  digital., 3  ij. 

Tinct.  nucis  vom., 3  iss. 

Spt.  ammon.  arom., 3  vi. 

Aq.  chlorof., ad  |  vi. 

M.  Sig.  Take  a  tablespoonful  every  three  or  four  hours 
in  water. 

Or, 

$  Ext.  convall.  maj., 3  i. 

Tinct.  scill., 3  ij. 

Syr.  prun.  virg.,       .        .        .        .        .        .     f  iss. 

Aquam, .       ad  §  vi. 

M.  Sig.  Take  a  tablespoonful  very  three  or  four  hours  in 
water. 

The  digitalis  must  not  be  pushed  to  the  point  of  nauseat- 
ing, nor  the  convallaria  to  that  of  relaxing  the  bowels.  In 
some  very  pronounced  cases  where  these  measures  failed,  the 
writer  has  got  excellent  results  from  2-grain  doses  of  citrate 
of  caffeine  thrice  daily,  with  cold-water  compresses  applied 
over  the  cardiac  region,  as  recommended  by  Schrotter.  Some 
able  physicians  caution  against  the  use  of  these  cold  applica- 
tions, but  the  writer,  who  has  employed  them  in  a  large  num- 
ber of  selected  cases  of  palpitation,  arising  both  from  organic 
and  functional  diseases  of  the  heart,  has  never  met  with  any 
untoward  result  from  their  judicious  employment. 

During  the  attack  the  patient  should  be  propped  up  in  bed; 
and  bromide  of  potassium  may  be  cautiously  given,  along 
with  a  stimulant,  such  as  brandy  and  water.  Morphine  in 
small  stimulating  doses  of  gr.  -fg  to  gr.  TV  administered  hypo- 
dermicalry,  is  of  great  service,  often  giving  instantaneous 
relief.  In  palpitation,  occurring  at  the  close  of  a  long  and  ex- 
hausting illness  and  causing  much  distress  and  sleeplessness, 
morphine,  evon  in  minute  doses,  is  not  free  from  risk,  as  it  oc- 
casionally induces  the  sleep  that  knows  no  waking,  and  that 


224  Insomnia  and  its   Therapeutics. 

without  producing-  any  of  the  symptoms  of  morphine  poison- 
ing. In  such  cases  the  induction  of  perspiration  is  the  most 
suitable  remed37,  for  in  them,  as  in  almost  all  forms  of  palpita- 
tion, sweating-  seldom  fails  to  give  more  speedy  relief  than 
any  sedative  medicine. 

In  the  aged,  no  remedy  seems  to  relieve  palpitation  and 
promote  sleep  so  well  as  a  teaspoonful  of  sal  volatile  and 
chloric  ether;  in  equal  parts,  in  water,  frequentty  repeated. 

In  palpitation  in  connection  with  hypertrophy  of  the  heart, 
as  in  the  gouty,  the  diet  must  be  attended  to,  nitrogenous 
food  being-  limited,  and  stimulants  forbidden. 

5,  lod.  potass.,      .        .        .        .        .        .        .    3  ij. 

Bicarb,  potass.,        .        .        .        .        .        .     3  iij. 

Tinct.  cimicifug-.,      .        ,        .        .        .        .     3  vi. 

Infus.  serpent.          .        .        .        .  ad  §  vi. 

M.     Sig.  Take  a  tablespoonful  thrice  daily  in  water. 

If  the  arterial  tension  be  pronounced,  TT[  ij.  of  tincture  of 
aconite  (B.  P.)  may  be  added  to  each  dose.  During-  the  attack, 
20  grains  of  chloral  hydrate,  or  from  2  to  8  grains  of  the  tan- 
nate  of  cannabin,  or  45  minims  of  paraldehyde,  may  be  given. 

The  treatment  of  palpitation  due  to  functional  causes  may 
be  considered  under  the  following  heads : 

Hcemic. — The  diet  and  regimen  must  be  reg-ulated  in  ac- 
cordance with  the  sug-g-estions  already  given  under  the  head 
of  cerebral  anaemia.  Cardiac  tonics  are  required,  while  the 
manufacture  of  blood-corpuscles  is  encouraged. 

]J  Pulv.  digital., g-r.  ss. 

Arsen.  sodii, gr.  -fo. 

Ferri  redact., gr.  iv. 

Ext.  calumb., q.  s. 

Ft.  pil.  i.     Sig.  Take  one  pill  after  meals  thrice  daily. 

For  immediate  relief  the  following  is  useful : 

^  Brom.  potass., 3  iij. 

Spt.  chlorof., 3  vi. 

Mist,  camph., ad  §  vi. 

M.     Sig.  Take  a  tablespoonful  every  hour  or  two. 

When  it  is  due  to  the  effects  of  disordered  metabolism, 
without  any  hypertrophy  of  the  heart,  the  diet  and  regimen 
must  be  arrang-ed  suitably;  while  mercurial  purg-atives  and 


Insomnia  and  its   Therapeutics.  225 

aconite  with  alkalies  are  indicated.     For  immediate  relief  the 
following-  will  be  found  useful: 

#  Tinct.  hyoscy.,         .        .        .        .        .        .    3  ss. 

Tinct.  cannab.  ind.,         .        .        .        .  .      .    ill  x. 

Mucil.  acac., 3  ij. 

Aq.  camph.,     ...        .        .        .      ad  3  ij. 

M.  f.  h.    Sig.  Take  at  once. 

The  skin  in  such  cases  demands  unusual  attention,  an  occa- 
sional perspiration  being-  invaluable.  Soap  should  be  freely 
used. 

Neurosal  palpitation,  such  as  arises  from  conditions  which 
induce  neurasthenia,  requires  the  diet  and  regimen  to  be  ad- 
justed on  the  lines  laid  down  when  writing  on  the  latter  sub- 
ject. Exercise  is  important,  and  gymnastics  are  to  be  pre- 
ferred to  walking.  In  those  in  whom  it  depends  primarily 
upon  ungratified  desires,  nymphomania,  etc.,  the  mental  ener- 
gies must  be  directed  into  new  and  healthy  channels,  and  all 
exciting  literature  and  day-dreaming  avoided.  Cold  or  tepid 
baths  are  daily  required.  Turkish  baths  are  also  beneficial. 
Tonics,  as  quinine,  phosphorus,  and  strychnine,  are  useful. 
For  the  attack,  the  patient  should  have  cold  applications  over 
the  heart,  and  if  it  has  disturbed  sleep,  he  may  wander  about 
the  bedroom  taking  an  air  bath,  and  sipping  occasionally 
some  cold  water.  The  valerianates,  with  ammonia,  camphor, 
and  chloric  ether,  may  be  given  freely.  Monobromide  of  cam- 
phor is  also  a  reliable  remedy.  When  palpitation  is  due  to 
reflex  irritation,  as  disorders  of  the  gastro-intestinal  canal,  or 
of  the  uterus,  ovaries,  etc.,  these  causes  must  be  remedied,  ere 
improvement  can  be  obtained. 

Toxic  palpitation  requires  the  abandonment  of  the  poison- 
ing agent,  e.gr.,  tea  or  tobacco. 

Dyspnoea. — This  is  a  symptom  of  almost  every  form  of 
heart  disease  and  aneurism.  It  is  distinct  from  the  breath- 
lessness  which  characterizes  pulmonary  and  other  complaints, 
and  which  will  not  be  discussed  here.  In  the  graver  cardiac 
lesions  it  is  often  associated  with  palpitation,  Cheyne-Stokes' 
respiration,  cardiac  pain,  and  angina  pectoris,  although  it 
may  alone  be  present.  It  may  exist  in  very  varying  degrees, 
in  some  instances  being  so  slight  as  to  be  perceived  only  after 
exertion,  or  when  breathing  a  close  atmosphere.  Some  pa- 


226  Insomnia  and  its  Therapeutics. 

tients  experience  it  only  when  sleeping-  in  a  badly-ventilated 
bedroom,  and  obtain  relief  simply  by  opening  the  door  or  win- 
dow. In  other  cases  it  comes  on  paroxysinally,  usually  during- 
sleep,  and  when  that  is  deepest,  at  a  time  when  the  respira- 
tory centres  are  working1  at  their  lowest  possible  level,  and 
consequently  more  liable  to  be  affected  by  an  altered  vascular 
supply.  The  implication  of  the  medullary  centres  is  further 
evidenced  by  the  sickness  and  vomiting,  which  occasionally 
terminate  these  nocturnal  attacks.  Irritability  of  these  cen- 
tres once  initiated  may  cause  breathlessness  from  the  most 
trifling  excitations,  or  perpetuate  it  for  a  time  after  they  are 
removed.  Lastly,  dyspnoea  may  be  constant  and  distressing, 
amounting1  to  orthopncea,  and  in  such  cases  the  symptom  is 
greatly  aggravated  if  any  attempt  be  made  to  resume  the 
recumbent  posture.  This  severe  breathlessness  is  usually 
associated  with  mitral  or  other  org-anic  disease  in  an  advanced 
stage,  in  which  dropsy  is  general,  and  has  supervened  in  the 
larger  cavities  of  the  body,  as  also  in  aortic  aneurism. 

Dyspnoea  depends  chiefly  upon  poisoning  of  the  respiratory 
centres  with  inadequately  oxyg-enated  blood,  and  this  may 
arise  from  an  excess  of  carbonic  acid  in  the  blood,  the  result 
of  impeded  circulation  in  the  lung's ;  or  it  may  be  due  to  a 
want  of  oxyg-en,  as  in  anaemia,  in  which  there  is  a  scarcity  of 
oxygen-carrying  corpuscles.  It  is  excited  by  blood  imperfectly 
depurated,  as  in  lithiasis,  and  especially  is  this  the  case,  when 
the  arterial  tension  is  increased. 

In  patients  predisposed  to  its  invasion,  it  may  be  inaugu- 
rated in  several  ways,  e.g.,  by  sleeping-  in  an  atmosphere  defi- 
cient in  oxygen.  The  respirations  during  sleep,  being1  fewer 
and  shallower,  the  want  of  oxygen  is  more  quickly  felt  than 
when  the  respirations  are  more  frequent  and  deeper.  By  im- 
pressions transmitted  to  the  respiratory  centres.  In  health, 
such  sensations  modify  the  character  of  the  breathing  during- 
sleep ;  it  is  not,  therefore,  surprising  that  in  diseased  condi- 
tions they  should  initiate  dyspnoea.  They  may  arise  in  any 
part  of  the  economy,  and  they  frequently  do  so  in  the  gastro- 
intestinal canal.  By  causes  which  embarrass  the  free  move- 
ments of  the  heart  and  lungs,  as  occurs  when  the  diaphragm  is 
pushed  up  by  a  distended  stomach,  an  incident  most  likely  to 
happen  in  the  recumbent  posture  during  sleep. 

Treatment. — It  is  impossible  to  discuss  the  treatment  of 


Insomnia  and  its  Therapeutics.  227 

dyspnoea  satisfactorily,  apart  from  the  conditions  upon  which 
it  depends.  We  may,  however,  indicate  generally  its  main 
lines. 

Posture  is  of  the  first  importance.  The  patient  should 
either  be  well  propped  up  in  bed,  or  sit  in  a  chair,  so  that  the 
capacity  of  the  chest  may  be  increased  as  much  as  possible. 

The  air  of  the  room  should  be  pure,  while  an  equable  tem- 
perature is  maintained,  and  draughts  avoided. 

The  digestive  processes  must  be  attended  to,  and  all  de- 
rangements rectified. 

In  those  grave  cases  of  advanced  disease,  associated  with 
relaxed  vascular  tension,  digitalis,  convallaria  majalis,  or 
strophanthus,  with  stimulants,  such  as  ammonia,  chloric  ether, 
etc.,  must  be  pushed  freely.  If  the  attack  terminates  sleep, 
a  minute  dose  of  morphine  (gr.  T^)  should  be  injected  hypoder- 
mically. 

When  the  tension  is  increased,  as  in  lithiasis,  nitrite  of 
sodium,  nitrite  of  amyl,  or  nitro-glycerin,  must  be  resorted 
to.  Anaemia  must  be  treated  in  the  usual  way,  arsenic  being 
preferred  to  iron.  A  dose  of  chloral  hydrate,  with  potassium 
bromide,  is  suitable  for  combating  the  seizure.  Belladonna, 
given  every  two,  three,  or  four  hours,  will  be  found  very  effica- 
cious. It  is  alleged  that  its  alkaloid,  atropine,  acts  upon  the 
constrictor  fibres  of  the  vagus,  paralyzing  them. 

Cheyne-Stokes'  Respiration. — This  peculiar  form  of  res- 
piration, first  recognized  by  Hippocrates,  has  been  variously 
designated  rhythmical  dyspncea,  ascending  and  descending 
respiration,  etc.  It  was  so  carefully  studied  by  Dr.  Cheyne 
and  Dr.  Stokes  that  their  names  are  now  commonly  asso- 
ciated with  it. 

It  is  met  with  chiefly  in  diseases  of  the  heart  and  head ; 
but  it  has  also  been  observed  in  febrile  affections,  as  typhoid 
fever,  diphtheria,  and  erysipelas;  and  in  morphine  and  chloral 
poisoning. 

It  is  usually  a  symptom  of  the  graver  forms  of  heart  dis- 
ease, such  as  fatty  degeneration,  dilatations  of  the  cavities  and 
aortic  lesions,  and  sometimes  occurs  in  the  process  of  dying. 
The  causation  of  this  symptom  is  obscure;  certainly  it  is  not 
definitely  known.  Tizzoni  discovered  "  histological  alterations 
in  the  bulb  and  pneumogastric  nerves."  The  late  Dr.  War- 
burton  Begbie,  in  discussing  the  historical  case  of  Philiscus, 


228  Insomnia  and  its   TJierapeutics. 

detailed  by  Hippocrates,  said :  "  Sleeplessness  was  a  notable 
feature;  and  although  the  febrile  condition  under  which  the 
patient  labored  ma}7  be  the  explanation  of  this  symptom,  it  is 
at  least  as  reasonable  to  suppose  that  the  neurosis  of  the 
vagus  on  which  the  peculiarity  of  his  breathing-  depended  was 
its  cause." 

Such  respiration  prevents  the  onset  of  sleep.  The  abject 
misery  which  a  patient,  thoroughly  worn  out,  suffers  in  strug- 
gling to  get  to  sleep  is  very  great  indeed,  and  can  only  be 
realized  by  those  who  have  experienced  its  terrors.  If  sleep 
be  not  obtained,  the  downward  progress  is  greatly  accelerated. 

Treatment. — Besides  the  treatment  of  the  disease  upon 
which  it  depends,  morphine  and  atrophine,  hypodermically  in- 
jected, are  the  two  remedies  worthy  of  confidence.  The  doses 
should  be  as  small  as  is  consistent  with  the  production  of  sleep. 

Pain  and  Angina  Pectoris. — These  are  by  no  means  rare 
concomitants  of  heart  disease,  indeed  pain,  more  or  less  intense, 
is  a  frequent  symptom  of  cardiac  and  aneurismal  affections. 
Cardialgia,  or  what  may  be  designated  pseudo-angina,  varies 
in  its  severity  and  duration;  it  may  be  slight  and  fleeting,  or 
severe  and  lasting..  It  usually  radiates  through  the  chest 
and  back,  but  it  may  affect  the  neck  and  jaws;  it  is  neuralgic 
in  character,  and  is  apt  to  be  mistaken  for  that  ailment,  espe- 
cially when  it  occurs  in  those  whose  nutrition  is  defective.  It 
may  awaken  a  patient  from  his  sleep,  and  sometimes  in  a 
terrifying  dream,  which  causes  him  great  distress.  A  patient 
lately  told  the  writer  that  she  was  only  conscious  of  dreaming 
thrice  in  her  life,  and  upon  each  occasion  (at  intervals  of  sev- 
eral years)  she  was  the  subject  of  cardiac  pain.  Occasionally 
it  seems  to  be  excited  by  indigestion  and  by  indiscretions  in 
eating  and  drinking,  as  well  as  by  over-fatigue;  also  by  anas- 
mic  conditions. 

Closely  allied  to  this,  but  of  far  more  grave  and  terrible 
import,  is  angina  pectoris,  or  breast-pang.  It  is  characterized 
by  paroxysmal,  agonizing  pain,  radiating  through  the  chest, 
back,  and  arms,  and  accompanied  by  an  overwhelming  sensa- 
tion of  suffocation  and  impending  death;  this  combination  of 
symptoms  never  failing  to  appall  the  sufferer. 

Its  pathogeny  is  by  no  means  definitely  ascertained. 
Whether  it  affects  primarily  the  cardiac  muscle  (spasm),  or 
the  cardiac  plexus  (neurosis),  is  unknown.  The  diseases  with 


Insomnia  and  its   Therapeutics.  229 

which  it  is  most  commonly  associated  are  well  recognized.  It 
occurs  most  frequently  as  a  symptom  of  fatty  degeneration 
of  the  heart;  and  in  diseases  occasioning-  a  sudden  constric- 
tion in  the  arterioles  throughout  the  body,  causing  a  painful 
distention  of  the  cavities  of  the  heart;  in  diseases  of  the  coro- 
nary arteries,  in  aortic  lesions,  and  in  aneurism;  although  it  may 
occur  in  almost  every  form  of  heart  disease.  That  it  is  asso- 
ciated with  heightened  tension  seems  undoubted.  Here  is 
Dr.  Balfour's  view  of  its  causation : 

"  I  believe  nwself  to  be  justified  in  saying  that  in  all  proba- 
bility the  predisposing  cause  is  anaemia  of  the  cardiac  plexus 
of  general  or  local  origin,  and  that  the  exciting  cause  is  some- 
thing which  directly  or  reflexly  still  further  cuts  off  the  sup- 
ply, or  in  some  other  mode  injuriously  influences  the  cardiac 
nerves.  These  exciting  causes  may  be  very  various;  in  some 
it  may  be  some  trifling  exertion,  in  others  the  depressing  in- 
fluence of  tea,  tobacco,  the  malarious  poison,  or  an}7  form  of 
gastric  irritation,  and  when  the  cardiac  nerves  are  in  a  state 
of  great  irritability  the  most  trifling  cause  may  give  rise  to  a 
severe  paroxysm/' 

Angina  pectoris  usually  comes  on  as  a  consequence  of 
mental  perturbation;  or  physical  exertion;  or  of  gastric  de- 
rangements, such  as  distention.  It  may  occur  at  any  hour 
of  the  day  or  night.  Sleep  is  the  common  time  for  such  seiz- 
ures, and  death  has  not  infrequently  taken  place  during  the 
night  from  this  cause.  The  writer  has  found  in  his  own  prac- 
tice that  the  favorite  times  for  this  occurrence  at  night  are 
immediately  after  going  to  bed,  which  he  ascribes  to  a  chill 
in  undressing  raising  the  blood  tension;  about  two  hours  after 
falling  asleep,  when  sleep  is  deepest;  and  about  four  or  five 
in  the  morning,  when  the  circulation  of  the  blood  is  most  de- 
pressed. 

The  attack  may  be  of  very  short  duration,  or  it  may  last 
for  a  considerable  time. 

Treatment.— It  is  important  that  the  bedroom  and  the  bed 
should  be  comfortably  warmed  in  the  case  of  patients  who 
have  suffered,  or  who  are  likely  to  suffer  from  angina  pectoris, 
so  that  all  risk  of  chill  may  be  avoided.  Great  attention 
should  be  paid  to  the  digestive  and  excretory  organs,  so  that 
derangements  may  be  forestalled.  Smoking  and  tea  drinking 
must  be  discountenanced.  Rest  of  body  and  peace  of  mind 


230  Insomnia  and  its   Therapeutics. 

are  essentially  necessary;  the  patient  should  be  enjoined  to 
live  rather  than  to  work.  In  short,  the  general  regimen,  diet, 
and  medication  should  be  regulated  in  accordance  with  the 
requirements  of  each  individual  case.  The  iodides  are  useful 
in  relieving  pain. 

$  lod.  potass.,          ...        .        .        .3  ij.-iv. 

Liq.  arsen.  sodii,  ...        .        .        .    3ij.-3i. 

Tinct.  digital.,      v 3  i. 

Aq.  chlorof., ad  3  vi. 

M.     Sig.  Take  a  tablespoonful  in  water  three  times  a  day. 

The  dose  of  the  digitalis  must  be  smaller  than  that  which 
will  raise  the  blood-pressure  unduly. 

The  nitrites  are  efficacious  in  allaying  pain  and  averting 
angina;  nitro-glycerin  may  be  given  in  doses  of  from  two  to 
four  minims,  of  a  one-per-cent  solution;  and  in  the  nitrite  of 
sodium  in  2-grain  doses  three  times  a  day.  Both  of  these 
medicines  are  more  slow  in  their  action  than  the  nitrite  of 
amyl,  but  their  effects  are  more  lasting.  When  an  attack 
supervenes,  nitrite  of  amyl  is  the  best  remedy;  from  two  to 
five  minims  should  be  inhaled  quickly.  Stimulants  are  like- 
wise called  for.  Morphine  is  an  invaluable  remedy,  speedily 
alleviating  the  distress,  and  promoting  sleep. 

Liegeois  counsels  against  the  use  of  antipyrine  in  angina 
pectoris,  pointing  out  that  as  it  is  a  vaso-motor  constrictor  it 
may  aggravate  the  attack.  (Phila.  "  Medical  Times,"  1888.) 

The  careful  and  judicious  inhalation  of  chloroform  or  ether 
is  sometimes  serviceable.  External  applications  of  mustard 
plasters,  or  turpentine  stupes,  and  a  hot  mustard  foot  bath, 
are  useful  adjuncts. 

Mitral  Insufficiency. — The  symptoms  are  well  marked. 
They  depend  mainly  upon  the  engorgement  of  the  venous  and 
capillary  systems  with  blood,  while  the  arterial  system  is 
greatly  impoverished.  This  leads  to  the  overloading  of  all 
the  organs  of  the  body  with  blood.  The  lungs,  liver,  kidneys, 
etc.,  all  suffer,  and  dropsical  effusion  into  the  cavities  and  sub- 
cutaneous tissue  follows.  There  is  usually  gastric  catarrh; 
and  the  digestive  derangements  which  it  and  the  hepatic  dis- 
orders cause  are  detrimental  to  sleep.  Palpitation  is  common. 
The  pulmonary  troubles  being  attended  by  breathlessness, 
frequently  demand  the  sitting  posture  for  the  maintenance 


Insomnia  and  its  Therapeutics.  23 1| 

of  respiration.  The  pulse  is  small,  soft,  frequent,  and  irreg- 
ular. 

Sleeplessness  is  mainly  due  to  passive  congestion  of  the 
brain,  which  leads  to  mal-nutrition  of  the  cerebral  cells;  and 
it  is  probable  that  sleep  is  still  further  disturbed  by  the  ir- 
regularity of  the  blood-supply. 

Such  patients  are  often  unable  to  fall  asleep;  they  are 
breathless,  and  may  suffer  from  Cheyne-Stokes'  respiration. 
Exhausted  to  the  last  degree,  they  sit  propped  up  in  a  chair 
or  in  bed,  with  heavy  drooping-  eyelids,  gazing  languidly 
around  in  despair.  Upon  attempting  to  sleep  they  nod  for  a 
moment  and  then  awake  with  a  start  as  if  being  suffocated, 
and  with  a  terrified  aspect.  After  a  short  time  the  process  is 
repeated.  If  eventually  they  sleep,  it  is  to  start,  twitch,  and 
dream,  and  the  dreams  being  of  a  horrible  description,  they 
awake  in  fright.  In  less  pronounced  cases,  patients  are  apt 
to  be  aroused  after  an  hour  or  two,  when  sleep  is  deepest,  by 
attacks  of  palpitation  and  d3'spnoea,  which  prevent  the  return 
of  sleep  for  some  hours. 

Treatment. — The  first  indication  is  to  secure  rest  for  such 
a  patient;  he  should  be  well  propped  up  in  bed  to  allow  the 
heart  as  much  room  to  beat  as  possible,  and  to  favor  the 
return  of  blood  from  the  head ;  indeed,  in  bad  cases  the  re- 
cumbent posture  cannot  be  assumed.  Everything  likely  to 
put  a  strain  upon  the  heart  or  to  enervate  the  nervous  system 
must  be  avoided.  The  food  should  be  light,  nutritious,  and 
as  concentrated  as  possible.  Alcohol  may  be  given  up  to  the 
point  of  improving  digestion.  The  bowels  must  be  kept  active; 
for  that  purpose  salines,  as  sodium  sulphate  or  Carlsbad  salts, 
with  an  occasional  dose  of  calomel  or  blue  pill,  suit  best. 
When  dropsy  is  present,  hydragogue  cathartics,  as  elaterium, 
gamboge,  or  jalap,  are  required. 

The  best  hypnotics  are  cardiac  tonics. 

#  Tinct.  digital., 3  ij.-  3  iij. 

Liq.  arsen., 3  ss. 

Acet.  potass., 3  vi. 

Infus.  scopar., ad  §  xij. 

M.  Sig.  Take  two  tablespoonfuls  thrice  daily  between 
meals. 

In  some  cases  the  following  answers  well : 


232  Insomnia  and  its   Therapeutics. 

#  Tinct.  ferri  raur.  (Ed.  Ph.),      .        .        .     3  iv. 

Hydrochlor.  ammon.,      .        .        .        .     3  iv. 

Tinct.  digital.,  .        .        ,        .        .        .3  ij.-iij. 

Tinct.  scill,       .        ...        .        .        .3  iij. 

Aq.  chlorof.,      .        .        .        .  ad  f  vi. 

M.    Sig.  Take  a  tablespoonful  in  water  thrice  daily. 

Should  the  digitalis  cause  increased  nausea  or  vomiting, 
strophanthus"  can  be  submitted  for  it.  Convallaria,  when  it 
does  not  purge,  frequently  acts  well. 

IJ  Ext.  convall.  maj., fl.  3  ij. 

Tinct.  nucis  vom., 3  ij. 

Tinct.  scill., 3  iij. 

Syr.  prun.  virg.,        .  ,  '     .        .        .3  xij. 

Aq.  chlorof.,       .        .        .        .        .        .      ad  3  vi. 

M.     Sig.  Take  a  tablespoonful  in  water  every  six  hours. 

The  citrate  of  caffeine,  in  doses  of  2  to  4  grains  three  times 
a  day,  is  beneficial  in  some  instances,  particularly  if  it  does 
not  produce  any  increase  of  headache.  It  certainly  tends  to 
promote  and  improve  sleep. 

Occasionally  these  tonic  remedies  fail  completely,  so  long 
as  the  dropsical  effusion  persists.  For  its  removal  mercurials 
and  pilocarpine  are  useful,  although  draining  the  fluid  off  by 
means  of  incisions  or  Southey's  tubes  offers  advantages. 

Till  the  improvement  sets  in,  when  sleep  naturally  returns, 
hypnotics  may  be  required.  Morphine  is  the  most  reliable 
remedy.  Dr.  Clifford  Allbutt  called  attention,  some  years  ago, 
to  the  great  value  of  hypodermic  injections  of  morphine  in 
these  cases,  allowing  the  patient  to  sleep  by  relieving  the  feel- 
ing of  suffocation.  Experience  has  confirmed  his  suggestion. 
The  writer  believes  that  in  small  doses  it  acts  as  a  tonic  to 
the  heart,  and  therefore  is  a  curative  agent. ,  The  best  dose 
to  begin  with  is  ^  of  a  grain. 

Chloral  hydrate  should  be  avoided  as  too  depressing. 

Paraldehyde  and  urethane  are  good  and  reliable  remedies 
when  morphine  is  contra-indicated. 

The  hypnotic  properties  of  alcohol,  and  of  diffusible  stimu- 
lants, such  as  chloric  ether  and  sal  volatile,  must  not  be  over- 
looked. 

Aortic  Incompetence. — There  is  usually  from  the  first 
some  dilatation  of  the  left  ventricle,  caused  by  the  reflux  of 


Insomnia  and  its   Therapeutics.  233 

blood,  but  a  hypertrophic  condition  soon  arises  to  compensate 
the  defective  arrangement.  So  long  as  the  hypertrophy  over- 
comes the  incompetence  things  go  on  comfortably,  but  when 
it  begins  to  fail^  the  left  auricle  is  implicated,  which  in  its  turn 
dilates  and  hypertrophies,  and  pulmonary  embarrassment 
ensues  with  all  the  characteristic  symptoms  of  mitral  regurgi- 
tation. 

Sleep  disturbance  in  the  early  stages  is  inconstant;  when 
it  does  occur  it  is  due  to  cerebral  anaemia  and  to  relaxed  vas- 
cular tension.  In  the  later  stages,  when  the  right  side  of  the 
heart  becomes  involved,  there  is  passive  congestion  super- 
added.  Many  such  sufferers  doze  and  sleep  in  their  chair 
during  the  day.  In  the  evening,  quite  overcome  with  sleep, 
they  go  to  bed,  but  immediately  on  assuming  the  recumbent 
posture  they  become  wakeful,  and  spend  the  night  in  watch- 
ing. The  other  disturbing  symptoms  are  palpitation,  dyspnoea, 
cough,  pain,  angina  pectoris,  and  gastralgia.  They  are  of  fre- 
quent occurence,  and  are  peculiarly  liable  to  come  on  during 
the  night. 

Treatment. — It  is,  in  the  main,  similar  to  that  of  mitral  in- 
sufficiency, but  it  demands  even  more  care.  The  patient  must 
be  encouraged  to  live  a  quiet,  regular,  and  uneventful  life,  all 
sudden  and  violent  exertion  being  interdicted.  Digitalis  must 
be  given  more  carefully  than  in  mitral  disease;  the  dose  must 
be  limited  to  that  which  will  tone  the  cardiac  muscle,  to  pro- 
mote hypertrophy  without  slowing  the  heart's  action.  Iron 
and  arsenic  may  be  pushed,,  and  everything  done  to  improve 
the  quality  of  the  blood  and  the  nutrition  of  the  body. 

For  the  promotion  of  sleep,  morphine  combined  with  atro- 
pine  is  most  generally  applicable.  Urethane,  paraldehyde, 
and  sulphonal,  in  the  order  mentioned,  are  excellent  remedies; 
it  is,  however,  well  to  combine  their  use  with  some  diffusible 
stimulant,  as  chloric  ether,  ammonia,  camphor,  or  brandy. 

In  cases  where  the  S3rmptoms  are  not  very  pronounced, 
the  administration  of  nitrite  of  amyl,  or  sodium  nitrite,  aids 
sleep.  It  is  judicious  to  follow  Dr.  Lauder  Brunton's  advice, 
and  direct  that  they  should  be  taken  only  in  the  lying  posture. 

Fatty  Degeneration  of  the  Heart.— Sleeplessness  may 
also  depend  upon  fatty  degeneration  of  the  heart,  which  is 
not  an  unusual  disease  in  the  gouty,  although  it  occurs  under 
many  other  conditions,  notably  in  diseases  interfering  with 
the  coronary  arteries,  as  well  as  in  dilatations  of  the  heart. 


234  Insomnia  and  its   Therapeutics. 

There  may  be  no  symptom  of  it  at  all,  except  dreaming 
and  disturbed  sleep,  and  its  presence  may  remain  unsuspected 
until  death  closes  the  scene.  It  is,  however,  more  usual  to 
have  evidence  upon  which  to  hinge  a  provisional  diagnosis  of 
fattjr  degeneration  of  the  heart.  The  aspect  changes;  the 
face  becomes  pale  and  anxious;  the  pupils  exhibit  the  arcus 
senilis;  the  skin,  pale  and  glossy,  assumes  perhaps  even  an 
unctuous  appearance;  the  extremities  are  prone  to  become 
cold,  especially  at  night;  the  temper  changes,  becoming  vari- 
able and  unreasonable,  with  feelings  of  weakness,  and  a  ten- 
dency to  giddiness  and  fainting  on  making  any  exertion.  The 
heart's  sounds  are  feeble;  the  first  sound  loses  its  distinctness, 
the  impulse  becoming  diffused  and  less  powerful;  sensations 
of  discomfort,  which  in  some  cases  amount  to  pain  in  the  car- 
diac region,  are  felt ;  the  pulse,  weak  and  irregular,  is  easily 
quickened  Toy  exertion,  but,  at  rest,  it  may  be  exceedingly 
slow — 30  to  40  per  minute.  Dyspnoea  on  exertion,  with  some 
lividity,  readily  occurs,  and  this  may  come  on  from  sitting  in 
a  close  atmosphere,  so  sensitive  are  these  patients  to  the  want 
of  air;  it  may  be  excited  even  by  indigestion.  They  sleep 
badly,  dream,  awake  often,  at  times  with  well-marked  dysp- 
noea, or  with  the  feeling  of  want  of  air.  They  ascribe  their 
awaking  and  asthma  to  the  quality  of  the  air  in  the  room. 
They  sleep  with  the  door  ajar. 

Treatment. — As  cardiac  asthma  is  liable  to  be  induced  by 
digestive  derangements,  the  food  must  be  carefully  regulated. 
Dry  concentrated  foods  usually  suit  best;  the  last  meal  should 
be  easy  of  digestion.  Alcohol  is  beneficial  in  this  form  of 
sleeplessness,  as  it  is  in  nocturnal  asthma.  There  is  truth  in 
the  old  saying,  that  a  man  with  a  weak  heart  should  be 
always  near  the  brandy  bottle,  if  seldom  at  it.  The  air  of  the 
sleeping  apartment  should  be  frequently  changed,  and  main- 
tained at  an  equable  temperature.  Repose  of  mind  and  body 
must  be  enjoined.  The  medicines  worthy  of  the  most  confi- 
dence are  arsenic,  iron,  digitalis,  and  strychnine.  The  bowels 
should  be  regularly  moved.  Sleep  is  promoted  by  the  following : 

]J  Spt.  chloroform., 3  vij. 

Spt.  ammon.  arom.,       .        .        .        ...     3  vij. 

Tinct.  bellad.,         .        .        .        .        .        .    3  ij. 

M.     Sig.  Take  a  teaspoonful  in  water  every  three  hours. 


Insomnia  and  its  Therapeutics.  235 

Also  by, 

1^  Bicarb,  sodii, 3  ij. 

Tinct.  lupul.,  .        .        .     '  ..        .        .        .     3  xij. 
Tinct.  sumbul.,        .        .        .  .        .3  xij. 

Infus.  serpentar.,    .        .        .        .        .      ad  §  vi. 
M.     Sig.  Take  a  tablespoonful  in  water  at  bedtime,  and 
repeat  if  necessary. 

Morphine  in  small  doses  is  admissible,  but  chloral  hydrate 
is  best  avoided. 

Aortic  Aneurism. — There  is,  perhaps,  no  disease  which  is 
attended  by  symptoms  so  diverse  in  their  character  and  sever- 
ity as  aortic  aneurism;  there  is  no  one  in  which  sleep  is  more 
curiously  influenced;  nor  any  in  which  the  want  of  sleep  is 
more  keenly  felt. 

So  long-  as  a  patient  with  an  aneurism  of  his  aorta  can  sleep 
soundly,  and  remains  free  from  pain,  he  maintains  his  appear- 
ance of  health  and  his  flesh  and  strength;  but  so  soon  as  he 
becomes  sleepless  he  grows  worn  and  wan,  he  emaciates  and 
loses  his  vigor,  and  the  fatal  termination  is  accelerated. 

It  may  be  that  a  patient  so  affected  sleeps  soundly  during 
the  whole  course  of  the  disease,  for  cases  have  occurred  in 
which  the  patient's  attention  was  first  attracted  to  his  condi- 
tion by  noticing-  a  bulging-  and  pulsating-  tumor  under  the  skin 
of  his  chest  wall. 

In  another  group  of  cases,  sleep  is  more  (but  not  gravely) 
interfered  with,  where  the  aneurism  is  just  above  the  aortic 
valves  at  the  sinus  of  Valsalva. 

In  the  majority  of  cases  there  is  much  suffering  and  sleep- 
lessness, and  these  depend  upon  cardiac  implication  leading 
to  circulatory  derangements,  pulmonary  and  bronchial  impli- 
cations, pain,  and  gastric  and  hepatic  derangements.  Aneur- 
ism is  usually  met  with  in  those  of  sanguine  temperament, 
and  who  have  a  hereditary  tendency  to  disease  of  the  heart 
and  blood-vessels;  and  at  the  time  when  active  and  violent 
work  is  usually  undertaken,  from  twenty  to  fifty  years.  It  is 
much  more  frequently  seen  in  males  than  in  females. 

The  symptoms  are  due  to  pressure  of  the  aneurismal  tumor 
upon  adjacent  structures,  and  to  changes  in  the  heart  itself. 
Pain  is  seldom  absent;  it  ranges  from  mere  discomfort  within 
the  thorax  to  constant  and  severe  pain,  which  is  either  neural- 


236  Insomnia  and  its  Therapeutics. 

gic  or  anginal  in  character,  its  direction  being  determined  by 
the  nerves  it  affects  directly  or  reflexly.  It  is  increased  by 
everything1  (as  excitement)  which  tends  to  augment  the  size 
of  the  tumor. 

Dyspnoea  may  be  trivial  and  only  noticeable  on  exertion, 
or  it  may  amount  to  persistent  orthopnrea,  with  violent  par- 
oxysmal exacerbations.  It  is  caused  by  the  condition  of  the 
heart,  by  pressure  on  nerves,  or  by  mechanical  interference 
with  the  respiratory  tract.  Nocturnal  seizures  interrupt  sleep. 

Treatment. — It  must  be  held  in  recollection  that  many  of 
these  symptoms  that  disturb  sleep,  as  pain,  dyspnoea,  etc., 
are  instigated  and  aggravated  by  increased  arterial  pressure 
within  the  aneurism;  it  is  therefore  important  that  the  iritra- 
arterial  tension  should  be  reduced  to,  and  kept  at,  the  mini- 
mum. To  accomplish  this  every  effort  must  be  made  to  se- 
cure absolute  repose  of  both  mind  and  body.  Best  is  the  best 
remedy  we  possess.  Reference  was  made  to  the  fact  (p.  595) 
that  in  one  of  Mr.  TufnelPs  cases  the  pulse  fell,  from  this  cause 
alone,  fifty  thousand  beats  in  twenty-four  hours.  Paroxysmal 
attacks  being  influenced  by  position,  it  is  necessary  to  give 
this  point  special  attention,  particularly  when  sleep  is  termin- 
ated by  nocturnal  seizures. 

In  the  majority  of  cases  the  diet  must  be  restricted.  Mr. 
Tufnell's  plan  was  to  allow  four  ounces  of  liquid  and  six  ounces 
of  solid  food  at  noon,  and  two  ounces  of  liquids  and  four  ounces 
of  solids  night  and  morning.  This  being  a  rigorous  diet,  it  is 
seldom  possible — even  in  hospital  practice — to  prevail  upon 
patients  to  adopt  it  in  its  entirety.  It  affords,  however,  a 
good  guide  to  the  essential  element  of  treatment. 

In  cases  in  which  anaemia  is  pronounced,  and  in  which  the 
anaemia  does  not  depend  upon  syphilis,  when  every  texture  of 
the  body  is  calling  loudly  for  oxygen,  it  must  ever  be  a  matter 
for  anxious  consideration,  whether  daily  driving  in  the  open 
air,  generous  diet,  and  a  small  quantity  of  red  wine,  does  not 
tend  to  prolong  life,  more  than  rest  and  restricted  diet. 

As  a  rule,  stimulants  should  be  dispensed  with ;  the  bowels 
kept  active  that  all  straining  at  stool  may  be  avoided.  Iodide 
of  potassium,  besides  being  curative,  possesses  sedative  prop- 
erties of  a  very  high  order,  soothing  pain,  relieving  breathless- 
ness,  and  frequently  promoting  sleep.  Most  patients  bear 
thirty  grains  three  times  a  day. 


Insomnia  and  its   Therapeutics.  237 

Antipyrine  has  lately  been  recommended  by  Professor 
Germain  See,  as  possessing1  the  power  of  quieting-  the  heart, 
and  so  favoring-  coagulation,  as  well  as  alleviating  distressing- 
thoracic  pain  and  cardiac  oppression  resembling  angina  pec- 
toris.  The  writer's  experience  of  its  use  in  a  recent  case  was 
not  encouraging ;  it  appeared  to  increase  the  distress  by  aug- 
menting the  arterial  tension.  Dr.  Dujardin-Beaumetz  concurs 
with  Professor  See,  but  prefers  phenacetin,  which  he  says  acts 
as  an  analgesic  in  half  the  doses  of  antipyrine,  and  he  adds 
that  it  is  not  poisonous. 

Individual  symptoms  require  in  many  cases  special  treat- 
ment. Pain  is  occasionally  relieved  by  cold  to  the  chest;  at 
other  times  by  moderate  bleedings;  and  also  by  anodyne  lini- 
ments. Dyspnoea  yields  to  the  inhalation  of  chloroform  or 
more  quickly,  perhaps,  to  the  hypodermic  injection  of  mor- 
phine. When  a  special  hypnotic  is  required  morphine  is  the 
drug. 


CHAPTER  XIII. 

INSOMNIA  DEPENDING  UPON  AFFECTIONS  OF  THE 
RESPIRATORY  SYSTEM. 

INSOMNIA  is  a  symptom  of  many  diseases  of  the  respiratory 
system,  in  some  cases  entailing  merely  increased  discomfort, 
in  others,  particularly  when  pronounced,  undoubtedly  exer- 
cising- a  prejudicial  influence  over  the  course  and  termination 
of  the  illness. 

It  is  a  matter  of  common  clinical  experience  that  many 
cases  of  pneumonia  and  bronchitis,  in  which  sleeplessness  is  a 
prominent  sj^mptom,  do  not  improve  until  sleep  takes  place, 
either  naturally  or  as  the  result  of  the  administration  of 
drugs.  During-  sleep  the  movements  of  the  lung-s  are  curtailed, 
the  amount  of  inspired  air  is  diminished,  the  blood-supply  is 
lessened,  and  recuperation  takes  place  in  the  heart  and  nerv- 
ous system,  all  of  which  tend  to  promote  recovery.  The  em- 
barrassed lung-s  and  bronchial  tubes  improve  under  the  influ- 
ence of  the  repose  in  a  very  remarkable  way. 

Sleep  can  often  be  secured  by  relieving-  the  conditions  upon 
which  the  insomnia  primarily  depends,  but  it  must  be  borne 
in  mind  that  in  every  case  the  cerebral  circulation  is  modified 
secondarily  in  some  degree,  and  that  the  selection  of  remedial 
ag-ents  should  be  g-uided  by  the  nature  of  these  modifications. 
Successful  treatment  demands  that  these  side  issues  be  con- 
sidered with  the  same  care  as  that  bestowed  upon  the  disease 
itself. 

Sleeplessness,  although  one  of  the  symptoms  of  the  dis- 
eases under  consideration,  is  in  reality  in  many  cases  a  precau- 
tionary arrangement  for  the  preservation  of  life.  It  enables  the 
patient  to  bring  to  the  aid  of  the  respiratory  muscles  all  the 
voluntary  help  he  possesses  to  assist  in  carrying  on  the  work 
of  respiration.  It  is  therefore  apparent  that  it  must  not  be 
interfered  with  recklessly,  for  in  such  instances  as  those  just 
referred  to,  the  induction  of  sleep  would  speedily  end  in  that 


Insomnia  and  its   Therapeutics.  239 

from  which  there  is  no  waking1.  In  no  class  of  diseases  is  it 
more  needful  to  remember  the  advice  of  the  father  of  physic 
to  "  do  no  harm." 

It  is  proposed  to  review  some  of  the  causes  which  disturb 
sleep  in  respiratory  diseases;  to  refer  to  the  abnormal  condi- 
tions in  the  nervous  system  which  these  instigate  and  perpetu- 
ate; and  to  suggest  treatment  which  has  been  found  reliable 
in  practice. 

Causes  which  disturb  sleep.  Among-  these  must  be  enumer- 
ated cough,  dyspnoea,  pain,  and  increased  temperature. 

Regarding-  cough  we  may  premise  that  it  depends  upon 
impressions  conveyed  by  afferent  nerves  to  the  centres  in  the 
medulla  oblong-ata  which  preside  over  coughing-.  These  may 
originate  in  the  terminal  ending's  of  the  nerves  in  almost  any 
organ,  or  in  the  cutaneous  or  mucous  surface  of  the  body. 
We  know,  for  example,  that  diseases  of  the  teeth,  ear,  or  nose 
are  all  provocative  of  cough,  not  to  speak  of  the  latter  being 
fruitful  sources  of  asthmatic  seizures.  Similar  causes,  acting 
in  other  parts  of  the  body,  may  reflexly  excite  cough. 

The  characteristics  of  irritative  cough  are,  that  it  is  ex- 
tremely frequent,  spasmodic,  and  paroxysmal,  and  not  accom- 
panied (for  obvious  reasons)  by  expectoration.  It  is  peculiarly 
liable  to  disturb  sleep.  When  the  terminal  endings  of  the 
nerves  in  the  respiratory  tract  are  unduly  sensitive,  this  de- 
scription of  cough  is  often  excited  by  cold  and  dust-laden  air; 
these  excitants  are  also  the  source  of  asthmatic  attacks. 

We  are  here  concerned  only  with  cough  as  it  is  excited  by 
abnormal  conditions  in  the  respiratory  system.  In  ordinary 
circumstances  it  is  designed  for  the  expulsion,  from  the  respira- 
tory tract,  of  foreign  materials,  or  of  secretions  when  these  are 
formed  in  abnormal  quantity.  During  sleep,  when  the  cen- 
tres for  coughing  are  in  a  state  of  repose,  they  fail  to  respond 
to  sensations  which  in  waking  moments  would  induce  the 
reflex  act. 

It  requires  a  more  powerful  stimulus,  or,  in  other  words,  a 
larger  accumulation  of  mucus  in  the  tubes,  to  excite  cough, 
although  when  this  does  occur  coughing  may  be  unusually 
severe  on  account  of  the  greater  quantity  of  material  to  be 
got  rid  of. 

When  the  mucous  membrane  of  the  bronchial  tract  is  un- 
duly sensitive  nnd  irritable,  the  most  trifling  provocations 


240  Insomnia  and  its  TJicrapeutics. 

initiate  sensations  which  are  transmitted  in  an  exaggerated 
way,  giving-  rise  to  a  dry,  irritating  cough,  which  accomplishes 
no  useful  purpose.  This  often  occurs  in  the  first  stages  of 
bronchitis  and  whooping  cough  when  the  tubes  are  h3Tpera> 
mic,  in  the  early  stages  of  pneumonia  and  phthisis  pulmonalis, 
and  in  laryngeal  phthisis  when  the  nerves  are  implicated. 

Superfluous  cough  of  this  kind  is  a  frequent  source  of  sleep- 
lessness, and  it  may  most  safely  and  advantageously  be  sub- 
dued. 

It  is  different,  however,  when  cough  is  perpetuated  by 
abundant  secretion,  as  in  the  advanced  stages  of  bronchitis 
and  phthisis  pulmonalis.  Here  the  accumulation  may  excite 
so  much  coughing  as  to  prevent  the  onset  of  sleep,  or  if  sleep 
has  supervened  it  may  interrupt  it  temporarily,  in  order,  if 
possible,  to  clear  the  bronchi.  When  cough  is  out  of  propor- 
tion to  the  work  done,  the  excess,  as  it  were,  may  be  cautiously 
curtailed,  so  that  its  frequency  and  severity  may  bear  some 
relation  to  the  amount  of  expectoration. 

In  cases  in  which  secretion  is  profuse,  and  where  the  pa- 
tient's whole  energies  are  required  for  breathing  and  expec- 
torating, to  induce  sleep  would  be  to  ran  the  risk  of  bringing 
about  fatal  asphyxia. 

Severe  paroxysmal  coughing  is  occasionally  due  to  exhaus- 
tion and  undue  irritability  of  the  medullary  centres,  for  al- 
though instigated  by  peripheral  irritation  the  excitability 
persists,  and  the  reflex  act  continues  long  after  the  necessity 
for  it  has  passed  away.  Under  certain  circumstances,  as,  e.g., 
in  some  cases  of  whooping  cough  and  pulmonary  phthisis,  this 
abnormal  excitability  exists,  and  the  slightest  stimuli,  such  as 
those  caused  by  draughts  or  by  changes  of  temperature,  are 
sufficient  to  set  up  paroxysms  of  coughing. 

Irritability  of  the  nervous  centre  which  governs  the  act  of 
coughing  is  exceedingly  apt  to  spread  to  those  in  its  immedi- 
ate neighborhood,  namely,  the  centres  for  vomiting  and  sweat- 
ing, and  the  vaso-motor  and  cardiac  centres.  This  explains 
the  vomiting  which  in  pertussis  and  phthisis  pulmonalis  so 
frequently  terminates  a  fit  of  coughing;  and,  to  a  certain 
extent,  the  perspiration  which  is  such  a  prominent  symptom 
in  the  latter  disease.  The  vaso-motor  centres  implicated  in 
this  way,  initiate  hypersemic  conditions  of  the  brain,  that  the 
patient  may  be  kept  awake  to  cough.  When  cough  is  very 


Insomnia  and  its   Therapeutics  241 

severe,  as  in  pertussis,  passive  cerebral  congestion  occurs, 
which  is  unfavorable  both  to  sleep  and  to  the  proper  nourish- 
ment of  the  brain.  The  lividity  of  the  face  during-  severe  fits 
of  coughing  in  this  disease  testifies  to  the  extent  of  the  venous 
congestion  present. 

Dyspnoea  in  diseases  of  the  respiratory  apparatus  depends 
upon  many  causes,  and  it  may  be  slight  and  constant,  or 
severe  and  paroxysmal.  It  is  sometimes  due  to  constriction 
of  the  lumen  of  the  respiratory  tract,  as  in  croup,  in  which 
the  inspirations  are  prolonged  and  stridulous,  and  the  urgency 
so  distressing  as  to  be  almost  incompatible  with  sleep.  As  a 
rule,  the  difficulty  of  breathing  in  such  instances  bears  some 
relation  to  the  obstruction  to  be  overcome. 

Dyspnoea  from  obstruction  may  also  be  paroxysmal,  and 
if  so,  is  almost  always  neurosal,  and  therefore  specialty  liable 
to  develop  during  sleep,  and  to  interrupt  it.  This  is  the  case 
in  the  sudden  seizures  of  laryngismus,  where  the  spasm  nar- 
rows the  larynx,  impedes  respiration,  and  causes  the  breath- 
ing to  be  stridulous  and  crowing;  likewise,  in  false  croup, 
which  closely  simulates  genuine  croup  in  its  dyspnoea!  symp- 
toms; and  also  in  asthma.  In  this  last  disease,  the  spasm 
contracting  the  lumen  of  the  bronchial  tubes  occasions  labori- 
ous breathing  and  wheezing,  accompanying  both  expiration 
and  inspiration.  The  expirations  are  so  unduly  prolonged, 
and  the  distress  so  great  altogether,  as  to  necessitate  the  sit- 
ting posture,  during  which  sleep  is  generally  impossible. 
Dyspnoea  is  less  pronounced  in  emphysema,  in  which  it  may 
amount  merely  to  a  prolongation  of  the  expiration,  with 
shortness  of  breath,  increased  upon  exertion;  but  it  is  more 
marked  in  bronchitis,  in  which  there  is  a  sense  of  constriction, 
oppression,  and  suffocation,  with  labored  breathing. 

Dyspnoea  is  increased  by  the  venosity  of  the  blood  circulat- 
ing through  the  respiratory  centres.  This  depends  primarity 
upon  defective  aeration  of  the  blood,  as  in  emphysema,  in 
which  duskiness  of  the  lips  and  face  is  seldom  absent.  It  is 
not  unusual  in  severe  bronchitis  with  profuse  secretion,  and 
although  not  often  met  with  in  phthisis  pulmonalis,  except  as 
the  result  of  some  complication,  it  is  sometimes  seen  toward 
the  termination  of  the  disease,  when  it  may  be  so  exaggerated 
as  to  cause  the  patient  to  struggle  for  breath.  Increased 
temperature  of  the  body  invariably  quickens  the  pulse  and 


242  Insomnia  and  its   Therapeutics. 

respirations,  and,  when  present,  helps  to  increase  the  rapidity 
of  the  breathing-  due  to  other  causes.  Implication  of  the  lung 
tissue,  as  in  phthisis  pulmonalis  and  pneumonia,  always  occa- 
sions an  increased  frequency  of  the  respirations,  in  order  to 
compensate  for  the  deficient  aeration  of  the  blood.  It  must 
not  be  forgotten,  however,  as  Cohnheim  pointed  out,  that  after 
the  crisis  in  pneumonia,  when  the  temperature  falls,  all  the 
symptoms  are  alleviated,  and  the  respirations  become  normal, 
while  the  lung1  is  still  hepatized  to  the  same  extent  as  before 
the  defervescence  took  place.  Of  equal  importance  are  those 
cases  depending  on  interference  with  the  expansion  of  the 
lung,  as  in  pleuritic  effusions,  etc.,  and  those  associated  with 
pain,  such  as  pleurisy  and  pleuro-pneumonia,  where  the  res- 
pirations are  voluntarily  diminished  in  depth,  and  consequently 
increased  in  frequency. 

Pain  is  another  of  the  symptoms  in  connection  with  res- 
piratory disease  which  often  exercises  a  disturbing  influence 
on  sleep.  It  quickens  the  pulse  and  induces  hypercemia  of  the 
brain.  The  pain  is  usually  increased  Toy  coughing,  deep  in- 
spiration and  movements,  explaining  the  instinctive  desire 
patients  have  to  inhibit  the  centres  for  coughing,  and  so  sup- 
press cough  voluntarily.  It  varies  in  character  from  the  sub- 
sternal  pain  of  bronchitis  to  the  sharp  and  piercing  pain  of 
pleurisy,  and  to  the  severe  pain  of  a  central  pneumonia,  in 
which  the  portion  of  lung  inflamed  gives  rise  to  considerable 
tension  on  the  neighboring  parts,  impressing  the  nervous  sys- 
tem unfavorably.  Such  cases  are  difficult  of  diagnosis,  per- 
cussion failing  to  elicit  a  dull  note,  or  auscultation  to  detect 
any  abnormal  sounds,  until  the  inflammation  makes  its  way 
to  the  surface.  Sleeplessness  in  such  cases  is  very  pronounced. 

Increased  body  temperature,  as  a  rule,  disturbs  sleep, 
mainly  in  proportion  to  its  height ;  it  is  thus  more  frequently 
a  source  of  sleeplessness  in  pneumonia  and  acute  phthisis  pul- 
monalis than  in  other  cases,  for  in  the  former  it  ranges  from 
103°  to  105°  Fahr.,  and  in  the  latter  it  reaches  105°  Fahr.  or 
more ;  and  these  patients  often  do  not  sleep  until  four,  five,  or 
six  A.M.,  when  the  fever  remits.  In  bronchitis,  even  capillary, 
it  seldom  exceeds  101°  to  103°  Fahr.,  the  pulse  being  rapid  in 
proportion  to  the  fever.  And  it  is  equally  true  of  pleurisy 
that  the  temperature  is  not  high  in  ratio  to  the  other  symp- 
toms. 


Insomnia  and  its   Therapeutics.  243 

It  might  here  be  added  that  the  night  sweats  of  phthisis 
are  most  apt  to  come  on  during  sound  sleep,  whether  by  day 
or  by  night,  thus  accounting  for  their  frequent  occurrence 
toward  morning,  when  the  remission  of  the  fever  admits  of 
sleep.  They  are  always  more  common  and  more  profuse 
when  coughing  is  unusually  severe,  and  they  tend  to  shorten 
sleep,  and  prevent  its  recurrence  when  it  has  been  once  dis- 
turbed. Dr.  Graves  wrote:  "It  is  between  three  and  five 
o'clock  in  the  morning  that  the  inclination  to  sleep  is  strong- 
est; it  is  about  this  time  that  sentinels  are  most  apt  to  slum- 
ber at  their  posts,  and  consequently  attacks  upon  camps  or 
cities,  made  with  the  intention  of  effecting  a  surprise,  are 
usually  undertaken  about  this  period  of  the  morning.  How 
well  marked  is  the  periodic  tendency  to  sleep  at  this  hour,  in 
all  patients  laboring  under  hectic  fever,  produced  \)y  what- 
ever cause !  How  often  do  we  hear  the  poor  sufferer  complain 
of  restlessly  tossing  about  in  his  bed  until  three  or  four  o'clock 
in  the  morning,  when  at  last  sleep,  welcome  although  uneasy, 
for  a  few  hours  separates  the  patient  from  his  pains ! "  This 
sleep  is  amply  accounted  for  by  the  remission  of  the  fever  and 
the  lowering  of  the  circulation,  which  usually  happen  at  that 
hour. 

The  abnormal  modifications  of  the  nervous  system  which 
are  induced  by  respiratory  diseases,  and  upon  which  disturbed 
sleep  really  depends,  will  be  best  noted  under  the  heading  of 
the  various  diseases,  and  treatment  will  also  be  thus  consid- 
ered. 

Whooping  Cough. — In  the  first  stage,  that  of  invasion, 
when  the  symptoms  resemble  those  of  an  ordinary  catarrh  or 
bronchitis  according  to  their  severity,  disturbed  sleep  and 
dreams  are  due  to  byperagmia  of  the  brain.  In  the  second 
stage,  when  the  characteristic  cough  becomes  the  marked 
feature  of  the  disease,  there  is  passive  congestion  of  the  brain, 
which,  besides  causing  sleeplessness,  accounts  for  the  number 
of  cerebral  affections  which  complicate  the  complaint.  In  the 
last  stage,  when  the  paroxysms  become  less  frequent  and 
severe,  and  when  the  patient  often  exhibits  symptoms  of  ex- 
haustion, impaired  sleep  is  due  to  anaemia  of  the  brain,  and 
night-terrors  not  infrequently  ensue. 

Treatment.— The  first  thing  is  to  secure  satisfactory  con- 
ditions of  sleep.  We  have  seen  that  irritable  nerves  transmit 


244  Insomnia  and  its   Therapeutics. 

impressions  very  readily;  hence  the  necessity  for  avoiding" 
draughts  of  cold  air  and  all  impurities  of  atmosphere.  The 
room  should  be  thoroughly  ventilated,  the  temperature  main- 
tained at  65°  Fahr.,  and  the  air  laden  with  a  certain  amount 
of  moisture  from  a  steam  kettle.  This  applies  to  all  acute 
diseases  of  the  bronchial  tubes.  In  whooping-  cough  it  is  spe- 
cially important  to  avoid  all  draughts.  Dr.  Eustace  Smith 
writes':  "  The  paroxysms  are  often  most  frequent  and  severe 
at  night  when  the  child  is  asleep.  The  slightest  movement  of 
air  across  the  face,  such  as  is  produced  by  a  person  walking 
near  the  cot,  will  often  excite  an  attack.  These  night  seizures 
can  usually  be  greatly  reduced  in  number  by  an  expedient 
suggested,  I  believe,  originally  by  Dr.  Marshall  Hall.  It  con- 
sists in  throwing  a  fine  rnuslin  curtain  over  the  cot  at  night- 
time. The  simplest  plan  is  to  have  a  couple  of  hoops  arranged 
at  the  ends  of  the  cot,  like  the  '  tilts '  of  a  wagon,  so  as  to 
support  the  curtain  at  a  sufficient  height.  This  arrangement, 
which  corresponds  to  the  mosquito  curtain  used  in  hot  cli- 
mates, does  not  interfere  with  a  free  supply  of  oxygen,  while 
it  effectually  stops  all  wandering  currents  of  air.  So  pro- 
tected, a  child  will  often  sleep  the  night  through  without  an 
attack." 

In  the  first  stage  the  general  treatment  must  be  derivative 
and  depressant;  expectorants  with  salines,  and  counter-irri- 
tants, as  mustard  and  linseed  meal  poultices,  being  useful. 
Sleep  is  best  induced  by  potassium  bromide  and  chloral  hy- 
drate. 

In  the  second  stage,  when  the  quantity  of  secretion  is  not 
abundant,  the  centres  for  cough  require  to  be  soothed.  The 
bromides  and  belladonna  are  here  specially  called  for.  It  is 
curious  to  notice  that  the  best  remedy  varies  with  the  epi- 
demic; what  suits  well  in  one,  fails  in  another;  while  the 
remedy  that  answers  well  in  any  given  epidemic  often  does 
so  in  all  the  cases.  To  get  good  from  medicines  they  must  be 
pushed.  In  the  case  of  belladonna,  it  is  often  marvellous  to 
note  the  improvement  which  follows  the  production  of  noisy 
and  hilarious  delirium  and  dilatation  of  the  pupils — the  physio- 
logical effects  of  the  drug.  Grindelia  is  also  a  useful  drug. 
When  there  is  much  secretion,  the  nightly  administration  of 
an  emetic,  such  as  sulphate  of  zinc  or  sulphate  of  copper,  acts 
as  ah  excellent  hypnotic.  The  passive  congestion  of  the  brain 


Insomnia  and  its   Therapeutics.  245 

is  best  treated  by  carbonate  of  ammonia  and  digitalis,  and 
stimulants,  as  alcohol  and  musk.     For  a  child  a  year  old  : 

5  Tinct.  digital., 3i.  to  3ss. 

Garb,  ammon., gr.  x. 

Spt.  chlorof., 3  ss. 

Syr.  tolu.,  ' 3  i. 

Aquam, ad  §  ij. 

M.  Sig.  Give  a  teaspoonful  three  or  four  times  a  day,  in 
a  little  water. 

Two  or  three  drops  of  tincture  of  musk  (U.S.P.)  may  be 
added  to  each  dose  when  there  is  much  depression.  Anti- 
P3rrine  is  said  to  answer  well  in  such  patients;  it  may  be  by 
raising  the  blood-pressure.  Paroxysmal  attacks  of  cough 
may  be  alleviated  by  the  inhalation  of  chloroform.  So  ad- 
vantageous is  this  that  children,  after  experiencing  its  bene- 
fits, will  not  leave  one  room  for  another  until  they  ascertain 
that  the  nurse  has  with  her  the  bottle  containing  it.  A  few 
drops  sprinkled  upon  a  handkerchief  should  be  held  to  the 
nostrils.  It  must  be  borne  in  mind  that  the  fewer  the  fits  of 
coughing  the  less  is  the  passive  cerebral  congestion,  and  the 
better  the  sleep.  If  any  hypnotic  is  required,  chloral  hydrate 
and  paraldehyde  are  suitable,  the  difficulty  with  the  latter 
being  its  taste. 

In  the  last  stage,  when  the  paroxysmal  cough  is  subsiding, 
and  anaemia  of  the  brain  replaces  passive  congestion,  iron,  qui- 
nine, and  alcohol  are  the  best  hypnotics.  Steel  wine  and  the  gly- 
cerin of  dialyzed  iron  answer  well,  while  change  of  air  acts 
beneficially.  Moiiobromide  of  camphor  and  belladonna  are 
occasionally  valuable  agents. 

Bronchitis.— Disturbed  sleep  depends  largely  upon  the 
severity  of  the  disease,  or,  in  other  words,  upon  the  extent  to 
which  the  smaller  tubes  are  implicated;  and  it  is  due  in  the 
earlier  stages  to  hyperaamia,  and  in  the  more  advanced  stages 
to  passive  congestion  of  the  brain. 

Treatment. — This  at  first  must  be  derivative  and  depress- 
ing in  the  majority  of  cases.  Hot  poultices  of  linseed  meal, 
sprinkled  with  cayenne  pepper  or  mixed  with  mustard,  or 
turpentine  stupes,  should  be  applied  to  the  chest  and  back  for 
a  short  time,  at  least  twice  in  twenty -four  hours;  the  chest 


246  Insomnia  and  its   Therapetitics. 

being-  protected  in  the  interval  with  a  swansdown,  or  extra 
flannel,  jacket.  Flying-  blisters  applied  to  the  limbs  are  use- 
ful auxiliaries.  They  are  decided  aids  to  sleep.  It  should  be 
remembered  that,  in  some  animals  whose  skulls  had  been 
trephined,  Schiller  saw  the  arteries  of  the  pia  mater  contract 
subsequent  to  the  application  of  mustard  to  the  abdomen. 

Dry  cupping1  the  back  and  chest  and  a  saline  purgative  are 
useful  expedients  for  depleting  the  brain  and  bronchial  tubes 
simultaneously.  Tartar  emetic  or  ipecacuanha,  with  nitrate 
of  potash  in  Mindererus'  spirit,  should  be  given  every  three  or 
four  hours.  In  the  gouty  the  following  answers  well: 

IJ,  Vini  antim.,      * 3  ij. 

Vini  colch.,        .        *        »        .        .        .        .  3  ij. 

Liq.  potass., 3  ij. 

Tinct.  camph.  co.,     .        .        .        .        .        .  f  i. 

Aq.  menth.  pip., ad  §  vi. 

M.  Sig.  Take  a  tablespoonful  every  three  or  four  hours,  in 
water. 

In  the  early  stages,  when  cough  is  not  required  for  the 
purpose  of  expelling-  phleg-m,  it  should  be  curtailed.  An  occa- 
sional dose  of  codeine  effects  this,  and  it  is  often  sufficient  to 
induce  sleep. 

•  * 

IJ  Syr.  codeinae, •     •    1  iss- 

Acid,  hydrocy.  dil., TT[  xxiv. 

Spt.  chlorof., 3  ss. 

M.  Sig-.  Take  a  teaspoonful  in  water  every  two  hours 
when  required  for  the  cough. 

If  sleep  be  not  induced,  two  teaspoonfuls  of  the  syrup  of 
chloral  hydrate  can  be  given  at  bedtime,  and  repeated  in  two 
hours  if  necessary.  Urethane  is  also  admissible  in  doses  of 
from  20  to  30  grains,  or  10  grains  of  Dover's  powder;  the  dis- 
advantage of  the  latter  being  its  tendency  to  derange  the 
secretions  and  to  constipate  the  bowels. 

When  the  bronchial  secretion  becomes  abundant,  cough, 
being  a  conservative  measure,  must  not  be  allayed;  on  the 
contrary,  its  expelling  power  should  be  improved,  if  possible, 
by  the  administration  of  stimulants.  Carbonate  of  ammonia 
and  nux  vomica  are  useful  remedies. 


Insomnia  and  its   Therapeutics.  247 

$,   lodid.  potass., 3  i. 

Carb.  ammon., 3  i. 

Tinct.  nucis  vomic., 3  i. 

Syr.  prun.  virg., =  iss. 

Aq.  chlorof., ad  3  vi. 

M.     Sig.  Take  a  tablespoonful  every  three  hours. 

To  procure  sleep  at  the  cost  of  checking  cough  would  obvi- 
ously be  highly  improper. 

If  the  secretion  be  very  profuse,  an  emetic  at  bedtime  is 
the  only  admissible  hypnotic.  For  the  adult  the  most  suitable 
emetic  is  sulphate  of  zinc  or  of  copper;  for  the  child  subsul- 
phate  of  mercury.  If  sleep  does  not  ensue,  it  is  generally  safe 
to  give  a  dose  of  paraldehyde  or  urethane  immediately  after 
the  tubes  have  been  emptied.  Opiates  are  contra-indicated, 
particularly  in  the  3roung  and  aged. 

Should  the  disease  linger  on,  efforts  must  be  made  to  check 
the  formation  of  the  secretion,  to  sustain  the  strength  of  the 
patient,  and  to  increase  the  efficiency  of  the  cough.  The  min- 
eral acids,  terebene,  quebracho,  tar,  the  benzoates,  sal  am- 
moniac, ammoniacum,  yerba-santa,  quillaya  saponaria,  are  all 
useful — turpentine  especially  so.  The  late  Dr.  Warburton 
Begbie,  describing  a  case  of  severe  bronchitis,  attended  by 
excessive  accumulation  of  secretion  in  the  bronchial  tubes, 
wrote:  "An  emetic  suggests  itself  as  a  likety  means  of  af- 
fording relief,  but  the  frequent  feeble  pulse,  and  the  clammy 
surface  of  the  body,  with  features  almost  collapsed,  and  livid 
lips,  forbid  its  employment.  Turpentine  is  then  an  alternative 
remedy,  and  it  is  a  safe  one;  given  internally  and  diligently 
applied  externally,  it  will  not  unfrequently  reward  the  confi- 
dence which  has  been  placed  in  it." 

In  like  cases,  sulphuric  ether  injected  hypodermically  in 
3  ss.  doses  frequently  affords  good  result,  strengthening  the 
heart,  augmenting  the  expelling  powers  of  the  cough,  and 
eventually  inducing  restorative  sleep.  Alcohol  in  its  various 
forms  may  be  given  freely  in  this  condition. 

Chronic  bronchitis  is  benefited  and  sleep  improved  by 
Turkish  baths,  and  by  change  of  residence  to  a  suitable  climate. 

Asthma. — Sleep  in  this  neurosal  affection  is  prevented  by 
the  extreme  difficulty  in  breathing,  and  by  the  passive  con- 
gestion of  the  brain  to  which  it  conduces.  The  following  re- 


248  Insomnia  and  its   Therapeutics. 

marks  do  not  refer  to  cardiac  or  anaemic  asthma,  or  that  which 
pertains  to  gout. 

Treatment. — At  the  onset  of  the  attack  the  best  remedies 
are  morphine,  gr.  £  to  gr.  £,  with  atropine,  gr.  yf^  by  hypoder- 
mic injection,  and  an  inhalation  of  nitrite  of  an^l  (TIL  iij.),  or 
of  chloroform.  Next  in  order  are  chloral  hydrate  3  ss.,  and 
potassium  bromide  3  ss.,  taken  in  the  form  of  a  draught,  and 
the  inhalation  of  the  fumes  of  Himrod's  cure,  or  of  Martin- 
dale's  pulvis  lobeliae  compositus.  The  extractum  grindeliae 
liquidum,  B.P.C.,  in  doses  ranging  from  TH,  x.  to  fT[  xxx.,  or  the 
tincture  of  lobelia  in  doses  from  "fT[  x.  to  m,  xxx.,  may  both  be 
advantageously  employed.  The  depressing  effects  of  the  lat- 
ter are  such  as  to  require  that  its  action  should  be  watched. 

Massage  of  the  spine  sometimes  shortens  and  alleviates 
the  attacks,  and  deserves  more  attention  than  it  has  hitherto 
received. 

In  the  intervals  between  the  attacks,  when  the  sleep  habit 
is  poor,  the  treatment  to  be  recommended  requires  considera- 
tion. When  the  malady  is  reflexly  occasioned  by  bronchitic 
or  catarrhal  affections  of  the  respiratory  tract ;  by  gastric  or 
intestinal  derangements;  lay  conditions  arising  out  of  a  dis- 
ordered metabolism;  or  by  abnormal  states  of  the  nasal  cavi- 
ties, attention  must  be  directed  to  the  relief  of  these  exciting 
causes.  When  it  results  from  an  inherent  proclivity  (idio- 
pathic  ?)  to  the  disease,  either  inherited  or  otherwise,  e.g.,  in- 
duced by  malarial  poison,  the  climatic  conditions  under  which 
the  patient  lives  demand  careful  investigation. 

Some  patients  sleep  best  in  densely-crowded  cities,  others 
in  the  country;  many  sleep  badly  at  the  seaside.  Their  ex- 
perience in  this  respect  is  of  the  first  importance  in  determin- 
ing a  suitable  residence,  for  no  climate,  however  salubrious, 
will  afford  benefit  unless  sleep  be  sound  and  undisturbed. 

Many  weakly  subjects  improve  by  sojourning  for  some 
months  at  the  Cape,  in  Egypt,  and  in  the  Riviera,  not  too 
near  the  coast.  Others,  who  have  a  tendency  to  obesity,  are 
benefited  by  periodic  visits  to  one  or  other  of  the  spas,  either 
at  home  or  abroad.  Electricity  has  rendered  good  service  in 
some  cases,  particularly  in  those  of  purely  neurosal  origin. 

In  all  cases  attention  must  be  paid  to  the  digestive  func- 
tions, and  Turkish  baths  advised,  in  selected  cases,  with  a 
view  to  improve  the  sleeping  habit. 


Insomnia  and  its   Therapeutics.  249 

The  prolonged  use  of  iodide  of  potassium  with  arsenic,  or 
of  small  doses  of  sodium  nitrite  or  nitre-glycerin,  improves 
sleep,  and  acts  as  a  prophylactic.  Paraldehyde  and  urethane 
are  eligible  hypnotics  for  temporary  relief. 

Hay  Fever. — In  this  affection  sleep  is  much  disturbed  by 
asthmatic  attacks,  arising-  from  the  irritant  action  which  the 
pollen  of  grasses  sets  up  in  the  mucous  membrane  of  the  eyes, 
nose,  and  respiratory  tract.  It  must  not  be  forgotten  that 
those  afflicted  with  this  affection  are  often  gouty  and  neurotic. 

Treatment. — Those  who  are  liable  to  this  complaint  should 
at  all  times  live  carefully,  but  especially  so  in  spring.  This  is 
desirable  for  the  purpose  of  maintaining  their  general  health 
at  the  highest  possible  point,  so  that  their  bodies  may  be  as 
little  vulnerable  as  possible.  The  weakly  often  benefit  from  a 
course  of  arsenic  or  quinine;  the  plethoric  from  ammonium 
chloride  or  potassium  iodide.  The  diathesis  must  be  nar- 
rowly studied. 

When  the  season  for  an  attack  is  due,  a  residence  at  die 
seaside  or  in  a  large  city  is  desirable;  although  in  a  very  dry 
hot  summer  the  quantity  of  fine  dust  constantly  floating 
about  in  the  atmosphere  of  a  city  is  provocative  of  asthmatic 
seizures. 

When  the  attack  supervenes  the  fluid  extract  of  grindelia 
robusta  and  chloral  hydrate  are  the  best  remedies.  Locally, 
swabbing  the  nostrils  with  a  solution  of  cocaine,  menthol  and 
iodine  in  vaseline  oil,  carbolic  douching,  and  the  use  of  car- 
bolized  smelling  salts,  are  probably  the  drugs  which  afford 
the  most  relief. 

Emphysema. —  This  frequently  follows  in  the  train  of  re- 
peated attacks  of  bronchitis  and  asthma,  as  well  as  whooping 
cough,  and  old  standing  tubercular  disease,  and  is  often  com- 
plicated by  sleeplessness,  depending  upon  slight  passive  con- 
gestion of  the  brain,  which  becomes  more  pronounced  when 
the  heart  gets  involved. 

Treatment. — In  the  early  stages,  careful  feeding,  avoidance 
of  cold,  the  administration  of  arsenic,  strychine,  and  cod-liver 
oil,  with  discreetly  regulated  Turkish  baths  at  stated  inter- 
vals, will  improve  sleep,  and  indeed  the  patient's  whole  tone. 
In  the  later  stages,  where  the  heart  is  affected,  mercurials, 
combined  with  salines  and  diuretics,  to  deplete  the  circula- 
tion, occasionally  afford  relief.  Tonics,  such  as  digitalis  and 


250  Insomnia  and  its   TJierapeiitics. 

strychnine  or  nux  vomica,  together  with  a  stimulant,  are  the 
safest  and  most  efficacious  hypnotics. 

1£  Tinct.  digital., 3  ij. 

Liq.  strychnin., 3  i. 

Tinct.  serpentar., 3  xij. 

Aq.  chlorof., ad  3  vi. 

M.     Sig.  Take  a  tablespoonful  thrice  daily  in  water. 

Alcohol  may  be  allowed  at  bedtime,  and  the  patient  should 
be  advised  to  sleep  with  a  high  pillow,  to  facilitate  the  return 
of  the  venous  blood  from  the  head.  Paraldehyde  is  probably 
the  best  hypnotic  we  possess  at  present  for  this  malady. 

Pneumonia. — Croupous  or  lobar.  Insomnia,  in  this  disease, 
depends  at  the  onset  upon  increased  vascular  tension  in  the 
cerebral  circulation;  during-  its  course,  upon  passive  conges- 
tion; and  toward  the  termination,  upon  anaemia  of  the  brain 
with  decreased  vascular  pressure. 

Treatment. — The  observation  of  Cohnheim  (page  740)  af- 
fords a  good  indication  for  the  treatment  of  this  insomnia. 
As  a  clinical  fact  sleep  is  best  secured  Toy  lowering  the  tem- 
perature. The  application  of  cold  also  acts  on  the  cerebral 
circulation.  Schiller  observed  that  cold  compresses  and  the 
cold  pack  produced,  at  first,  dilatation  of  the  arteries  of  the 
pia  mater,  but  afterward,  contraction  of  these  vessels — a  con- 
dition favorable  for  sleep. 

In  the  young  and  strong,  the  application  of  cold  iced  cloths 
to  the  chest,  frequently  changed,  fulfils  these  conditions,  par- 
ticularly if  quinine  and  aconite  be  administered  concurrently. 
Aconite  possesses  the  power  of  lessening  the  conductivity  of 
the  sensory  nerves,  and  this,  by  relieving  pain,  conduces  to  sleep. 

$  Sulph.  quinin., gr.  xx. 

Ext.  aconit., gr.  i. 

Ft.  pil.  iv.     Sig.  Take  two  at  four  and  six  P.M. 

At  the  onset,  opium  with  antimony  is  a  suitable  and  useful 
combination.  However,  when  there  is  much  secretion,  and 
when  the  respirations  are  irregular  and  shallow,  opiates  must 
be  cautiously  used.  Antipyrine,  given  in  15-grain  doses  every 
hour  for  four  or  six  hours,  serves  a  similar  purpose,  although 
it  acts  less  satisfactorily  when  the  arterial  tension  is  very 
marked. 


Insomnia  and  its   Therapeutics.  251 

In  the  debilitated  and  aged,  hot  poultices  may  be  applied 
to  the  affected  side,  and  a  mixture  something-  like  the  follow- 
ing given : 

$  Garb,  ammon., 3  i. 

Tinct.  belladon.,         .        .        .        .       3  i.  vel  3  iss. 

Liq.  strychn., 3  i. 

Infus.  serpentar., ad  §  vi. 

M.     Sig.  Take  a  tablespoonful  every  four  hours  in  water. 

When  special  remedies  are  required  to  promote  sleep, 
chloral  hydrate  with  potassium  bromide,  or  paraldehyde  alone, 
may  be  prescribed  during  the  first  few  days;  and  in  the  later 
stages,  morphine,  gr.  J-  to  \,  with  atropine,  gr.  T^,  an  hour 
before  bedtime.  Sponging  the  body  with  tepid  water,  and  a 
timely  dose  of  alcohol  with  a  light  meal,  are  often  followed 
by  refreshing  sleep. 

In  grave  cases,  occurring  particularly  among  the  aged, 
and  in  those  who  have  lived  freely,  cardiac  exhaustion  endan- 
gers life.  The  symptoms  are  a  running,  irregular,  and  inter- 
mitting pulse,  140  to  180,  quickened  respirations,  50  to  60,  and 
sometimes  a  temperature  of  105°  to  106°  Fahr.  The  sufferer 
being  anxious  and  distressed,  if  he  sleeps  it  is  to  mutter  and 
talk  for  a  few  moments,  and  then  to  waken  with  a  start.  Opi- 
ates are  out  of  the  question.  Such  cases  are  too  weak  to  sleep. 
Sulphuric  ether  injected  hypodermically  will  often,  in  these 
cases,  slow  and  steady  the  pulse,  strengthen  the  heart,  lower 
the  temperature,  moderate  the  respirations,  increase  the  power 
to  expectorate,  and  bring  about  peaceful  sleep.  The  writer 
has  repeatedly  seen  apparently  hopeless  cases  recover  under 
this  treatment.  In  very  urgent  cases  it  must  be  injected  every 
hour.  Alcohol  and  musk  may  be  given  at  the  same  time  by 
the  mouth. 

Phthisis  Pulmonalis. — Dreams  of  a  terrifying  nature  and 
disturbed  sleep  are  among  the  many  premonitory  symptoms 
of  this  disease.  So  substantially  true  is  this,  that  the  writer 
has  been  able  frequently  to  rightly  predict,  from  their  occur- 
rence, the  onset  of  the  disease,  while  as  yet  no  other  symptom 
appeared  to  justify  the  diagnosis.  They  depend  largely  upon 
the  anaemia  and  digestive  derangements  which  so  frequently 
prelude  it,  and  initiate  irritability  in  the  cerebral  cells. 

Treatment. — Besides  attending  to  digestion,  nutrition,  and 


252  Insomnia  and  its   Therapeutics, 

decubitus  (which  latter  should  be  that  instinctively  chosen  by 
the  patient)  the  cough  must  be  curtailed  to  the  point  of  use- 
fulness. Codeine  answers  well  and  does  not  derange  the  di- 
gestive processes  like  opium  or  morphine — a  most  essential 
attribute  in  a  debilitating  disease. 

IJ  Codeinae,          .        .        .        .        .     gr.  iij.  vel  gr.  iv. 

Acid,  hydrocyan.  dil., TTJ,  xxiv. 

Acid,  phosphor,  dil., 3  i. 

Glycerin., 3  vi. 

Aq.  chlorof., ad  §  vi. 

M.  Sig.  Take  a  tablespoonful  when  the  cough  is  trouble- 
some, and  repeat  if  required  every  two  or  three  hours. 

For  a  time  this  seldom  fails  to  soothe  and  admit  of  sleep. 
Where  it  is  insufficient,  ten  grains  of  chloral  hydrate,  or  one 
of  the  following,  may  be  given  at  bedtime :  ten  to  fifteen  min- 
ims of  chlorodyne;  3  ss.  of  the  ammoniated  tincture  of  opium 
(Scotch  paregoric  elixir);  3  ss.  to  3  i.  of  compound  tincture  of 
camphor  (English  paregoric);  each  separately  acts  in  differ- 
ent cases  satisfactorily.  Occasionally  it  may  answer  the  pur- 
pose to  give  a  morphine  or  cocaine  lozenge,  or  better  still  a 
few  whiffs  of  chloroform.  Alcohol  at  bedtime,  with  a  flying 
blister  of  mustard  or  turpentine,  is  worthy  of  a  trial.  When 
the  expectoration  is  copious,  care  must  be  taken  not  to  inter- 
fere further  than  to  allay  the  superfluous  coughing.  Much 
may  be  done  by  controlling  the  bulk  of  the  sputum  and  by 
strengthening  the  powers  of  expulsion.  The  acids  with  squills 
and  strychnine,  or  cubebs  with  wild  cherry  and  terebene,  are 
both  suitable  combinations.  When  a  direct  hypnotic  .is  called 
for  to  obtain  sleep,  either  paraldehyde  or  urethane  may  be 
given. 

When  fever  runs  high  it  must  be  controlled.  Quinine  acts 
as  a  hypnotic. 

IJ  Sulph.  quinin., gr.  viij. 

Pulv.  digital., gr.  i. 

Ext.  opii, gr.  \. 

Ft.  pil.  ij.     Sig.  Take  at  four  P.M.  and  repeat  at  6  P.M. 

The  application  of  cold-water  cloths  for  an  hour  or  two 
before  bedtime  answers  the  same  end. 

In  chronic  cases  the  administration  of  six  grains  of  anti- 


Insomnia  and  its   Therapeutics.  253 

febrine,  about  four  and  six  P.M.,  with  free  sponging-  with  tepid 
water  at  bedtime,  is  conducive  to  sleep.  The  inunction  of 
cocoa-nut  oil  is  useful,  the  friction  appearing-  to  promote  sleep. 
Dyspnoea  in  this  disease  is  most  speedily  relieved  by  the  hypo- 
dermic injection  of  sulphuric  ether. 

Haemoptysis  very  frequently  supervenes  during  sleep. 

Pleuritis. — Insomnia  is  due  chiefly  to  cerebral  hyperaemia 
in  the  early  stages,  and  to  anaemia  in  the  later.  It  is  some- 
times one  of  the  few  symptoms  of  latent  pleurisy,  and  may 
even  be  the  only  one. 

Treatment. — Attention  to  decubitus.  At  first,  relief  from 
pain  (by  restricting  movement)  is  gained  by  lying-  upon  the 
affected  side,  an  end  which  may  also  be  attained  by  the  appli- 
cation of  a  firm  bandage.  In  the  more  advanced  stages  prop- 
ping up  the  patient  in  bed  often  promotes  sleep.  The  treat- 
ment must  be  decidedly  antiphlogistic.  Morphine,  with  or 
without  atropine,  is  the  only  reliable  hypnotic,  and  effusion  is 
no  bar  to  its  use ;  the  dose  oug-ht  to  be  as  small  as  is  corn- 
pa  tible  with  the  end  to  be  attained.  Paracentesis  is  invari- 
ably followed  by  improved  sleep. 

Laryngismus  Stridulus.  —  This  neurosal  affection  fre- 
quently interrupts  sleep  at  its  deepest.  It  occurs  in  those  pos- 
sessing unstable  nervous  systems,  whether  inherited  or  induced 
by  mal-nutrition,  such  as  arises  from  improper  feeding-,  e.g.,  poor 
milk,  or  an  excess  of  starchy  food;  and  unhealthy  surround- 
ings. In  this  debilitated  state  there  is  a  tendency  to  explosive 
attacks  when  the  respiratory  centres  are  slumbering-  deeply, 
and  these  are  easily  excited  by  reflex  irritations,  such  as  teeth- 
ing, gastric  derang-ements,  worms,  etc.  The  inherent  weak- 
ness in  the  cerebral  textures  renders  these  infants  at  all  times 
restless  and  fitful  sleepers,  awaking-  often  and  crying.  The 
affection  is  most  frequently  met  with  in  rickety  children,  and 
also  in  the  victims  of  hereditary  syphilis. 

Treatment. — This  naturally  divides  itself  under  three  heads. 
The  first  includes  the  removal  of  the  exciting-  cause,  and  atten- 
tion to  the  tone  of  the  nervous  system,  by  means  of  hygiene, 
proper  food,  tonics,  etc.;  the  second  embraces  the  adoption  of 
prophylactic  measures,  such  as  the  cold  bath,  spong-ing-  the 
throat  several  times  a  day  with  cold  water,  administering-  a 
nightly  dose  of  potassium  bromide  and  chloral  hydrate,  which 
children  bear  well,  attending  to  the  ventilation  of  the  bed- 


254  Insomnia  and  its   Therapeutics. 

room  and  to  the  bed-clothing1,  etc.;  the  third  deals  with  the 
attack  itself.  The  writer  has  been  accustomed  to  advise  that 
the  nurse  should  always  have  at  hand  a  basin  containing  cold 
water  and  a  sponge,  and  a  phial  of  one  part  of  chloroform 
mixed  with  three  parts  of  spirits  of  wine,  that  the  former  may 
be  immediately  dashed  over  the  face  and  chest,  and  a  few 
drops  of  the  latter  sprinkled  on  a  handkerchief  and  held  to 
the  nostrils.  Nitrite  of  amyl  may  also  be  used.  In  very 
young-  children  smelling  salts  may  be  substituted  for  the 
chloroform.  In  severe  cases  musk  and  ammonia  are  excellent 
remedies.  Opiates  are  usually  injurious.  Cod-liver  oil  usually 
affords  good  results  when  given  between  the  seizures. 

Spurious  Croup. — This  malady  occurs  in  the  same  class  of 
patients,  and  by  many  is  considered  to  be  one  and  the  same 
disease;  it  attacks  those  of  older  years,  from  one  to  seven. 
It  invariably  comes  on  at  night,  during  the  first  two  hours  of 
sleep,  when  it  is  deepest.  The  child  suddenly  awakes  gasping 
for  breath,  flushed,  distressed,  and  alarmed;  tosses  about  as 
if  looking  for  relief,  and  not  finding  it,  cries.  The  attack  does 
not  usually  last  more  than  half  an  hour,  though  it  may  recur 
the  same  night  when  sleep  again  becomes  sound,  and  it  almost 
always  does  so  on  the  succeeding  nights.  At  times  it  is  pre- 
ceded by  eatarrhal  conditions  of  the  nostrils  and  throat.  This 
is  a  eatarrhal  affection  with  a  neurosal  element  superadded. 

Treatment. — This  consists  in  affording  relief  at  the  time, 
and  subsequently  attending  to  the  general  condition  of  the 
patient.  Two  or  more  grains  of  the  subsulphate  of  mercury 
in  a  teaspoonful  of  water  induces  emesis  rapidly,  and  the  ap- 
plication of  hot  poultices,  or  a  hot  sponge  to  the  throat  for 
half  an  hour,  often  suffices  to  relieve  the  cough  and  distress, 
and  to  render  the  breathing  easy  and  comfortable.  If  it  does 
not,  the  cautious  administration  of  minute  doses  of  aconite  is 
desirable.  The  after-treatment  consists  in  the  use  of  tepid 
salt-water  baths  and  suitable  tonics. 


CHAPTER  XIV. 

INSOMNIA  DEPENDING   UPON  FEBRILE  AND  GENERAL 

DISEASES. 

THE  constitutional  disturbance  which  arises  from  the  vari- 
ous specific  fevers  invariably  affects  the  nervous  system.  In 
a  large  percentage  of  cases  this  is  apparent  in  the  stage  of 
invasion,  by  depression,  headache,  and  sleeplessness;  through- 
out the  course  of  the  fever,  by  disturbed  sleep  and  delirium, 
more  rarely  by  convulsions  and  coma;  and  occasional^',  in 
convalescence  (e.g.,  in  enteric  fever),  by  mental  enfeeblement, 
and  in  some  instances  by  well-marked  insomnia. 

Sleeplessness  usually  depends  in  the  earliest  stage  upon 
circulatory  derangements;  and  subsequently,  upon  an  enfee- 
bled state  of  the  cerebral  cells,  brought  about  by  defective 
nutrition. 

At  the  onset  of  the  fever  there  is,  in  most  cases,  anaemia  of 
the  brain  with  increased  vascular  tension,  the  blood-vessels 
being  tonically  contracted  and  the  pulse  hard  and  incom- 
pressible. Cerebral  irritation  thus  induced  gives  rise  to  head- 
ache, sensory  derangements,  restlessness  and  sleeplessness, 
followed  or  accompanied  by  profound  malaise,  and  muscular 
and  articular  pain.  In  children,  convulsions  may  occur,  par- 
ticularly in  measles,  without  any  serious  after-effects.  The 
anaemia  of  the  cutaneous  surface,  rendering  it  unduly  sensitive 
to  all  impressions,  occasions  the  sensations  of  chilliness  and 
shivering. 

This  state  is  replaced  after  a  time,  longer  or  shorter,  by  a 
reversed  condition  of  things,  in  which  the  blood  reaches  the 
brain  and  surface  through  relaxed  blood-vessels  (and  with 
lowered  tension).  The  temperature  of  the  body,  increasing 
from  the  beginning  up  to  its  maximum,  causes  much  heat  to 
be  given  off  by  the  skin,  which  feels  dry  and  pungent.  The 
pulse  becomes  quicker,  fuller,  and  softer.  In  this  stage  the 
brain  and  nervous  system  are  practically  starved.  A  rapid 


256  Insomnia  and  its  Therapeutics. 

circulation  being  at  all  times  badly  adapted  for  the  removal 
of  the  waste  products  from,  and  for  the  supply  of  healthy 
pabulum  to,  the  tissues,  it  is  still  more  embarrassed  in  the 
discharge  of  its  functions  by  being  surcharged  with  morbid 
materials,  inseparable  from  an  enormously  increased  tissue 
metamorphosis;  and,  it  may  be,  with  those  elementary  and 
poisonous  substances  which  initiate  the  disorder. 

The  effects  of  this  starvation  are  displayed  in  prostration, 
mild  delirium,  restlessness,  and  sleeplessness;  and  in  grave 
cases,  by  convulsions  arid  coma. 

Toward  the  termination  of  the  fever  the  heart  becomes 
feeble,  the  pulse  quicker  and  dicrotic,  and,  coincidently,  the 
nervous  system  is  more  profoundly  exhausted. 

In  no  class  of  cases  is  sleep  of  more  importance,  the  want 
of  it  influencing  the  course  and  termination  of  the  diseases 
most  unfavorably.  The  late  Dr.  Murchison  wrote:  "The 
practitioner  cannot  be  too  forcibly  impressed  with  the  fact 
that  loss  of  sleep,  at  any  stage  of  typhus,  if  it  continue  for 
two  or  three  nights,  is  of  itself  sufficient  to  kill."  On  the 
other  hand,  sleep,  even  of  limited  duration,  never  fails  to  act 
beneficially;  to  secure  it  for  a  patient  is  in  many  instances 
tantamount  to  insuring  his  recovery.  Sleeplessness  may  be 
taken  as  an  indication  of  the  gravity  of  the  disease,  particu- 
larly if  it  resist  treatment.  It  must,  of  course,  be  borne  in 
mind  that  the  greatest  differences  exist  in  the  ability  of  pa- 
tients to  sleep  under  feverish  conditions;  those  possessing 
excitable  and  impressionable  nervous  systems  sleeping  very 
badlr.  It  is  therefore  doubly  important  to  promote  sleep  in 
their  case. 

To  illustrate  the  management  of  insomnia  in  febrile  condi- 
tions it  is  proposed  to  discuss  the  symptoms  of  typhus  and 
enteric  fevers  at  some  length,  those  of  measles  and  scarlet 
fever  being  alluded  to  very  briefly. 

Typhus  Fever. — As  the  full  brunt  of  typhus  fever  is  borne 
by  the  nervous  system,  sleep  disturbance  of  a  severe  nature  is 
of  frequent  occurrence.  The  invasion  is  usually  sudden,  oblig- 
ing the  patient  to  relinquish  his  occupation  and  betake  him- 
self to  bed.  He  complains  of  headache,  great  depression,  and 
of  articular  and  muscular  pain.  Sleeplessness  is  present  more 
or  less  throughout  the  illness.  Among  the  other  symptoms 
are,  a  pulse  full  at  first  (less  hard  than  an  ordinary  febrile 


Insomnia  and  its   TJierapeutics.  257 

pulse),  afterward  full  and  soft;  a  high  temperature;  and  a 
scant}'  flow  of  urine,  containing  a  greatly  increased  quantity  of 
urea.  When  the  vascular  tension  relaxes,  the  headache  dis- 
appears and  gives  place,  in  a  well-marked  case,  to  muttering 
delirium,  the  patient  lying  in  an  apathetic  state,  with  his  in- 
tellect clouded  and  confused,  answering  questions  slowly,  if  at 
all;  or  his  delirium  majr  be  excited,  though  it  is  usually  less 
so  than  that  of  delirium  tremens;  or  he  may  gravitate  into 
the  condition  known  as  coma  vigil,  and  lie  with  his  eyes  wide 
open,  apparently  unconscious  of  all  that  is  going  on,  and  pick- 
ing at  the  bed  clothes,  etc. 

It  will  be  useful  to  inquire  into  the  condition  of  the  brain 
and  nervous  system  in  this  disease  with  reference  to  sleep. 
After  death  the  brain  has  been  found  atrophied,  and  the  sub- 
arachnoidal  fluid  increased.  In  a  small  proportion  of  the  cases 
there  was  an  "  increased  vascularity  of  the  meninges."  Dr. 
Murchison  wrote :  "  The  increased  vascularity  of  the  cerebral 
membranes  in  typhus  must  not  be  regarded  as  a  sign  of  in- 
flammation, and  does  not  account  for  the  cerebral  symptoms 
observed  during  life.  The  vascularity  is  not  greater,  or  more 
common,  than  when  death  results  from  disease  of  the  lungs; 
and  in  most  cases  where  it  is  increased,  some  impediment  will 
be  found  in  the  pulmonary  circulation,  or  there  has  been  evi- 
dence of  greatly  impaired  cardiac  action.  ...  I  have  repeat- 
edly known  the  most  severe  cerebral  symptoms  during  life, 
without  abnormal  vascularity  of  the  cerebral  membranes  after 
death."  This  indicates,  with  tolerable  conclusiveness,  that  the 
nervous  symptoms  in  typhus  are  not  the  result  of  inflamma- 
tory changes  in  the  brain  or  its  membranes.  On  the  contrary, 
they  are  due  to  mal-nutrition.  It  is  evident  that  the  poison- 
laden  blood,  which  perverts  the  secretions,  destroys  the  appe- 
tite and  deranges  all  the  digestive  processes,  and  subsequently 
modifies  the  nutrition  of  the  mucous  membranes  and  skin, 
must  be  inadequate  for  the  nourishment  of  the  delicate  and 
sensitive  textures  of  the  nervous  system.  Not  only  are  they 
deprived  of  recuperative  pabulum,  but  they  are  poisoned  by 
the  toxic  constituents  of  the  blood.  If  further  proof  of  their 
mal-nutrition  be  required,  it  is  found  in  the  exaggerated  knee- 
reflex  and  ankle-clonus,  which  can  be  elicited  in  the  majority 
of  cases  of  severe  and  prolonged  fevers. 

Treatment. — A  thoroughly  comprehensive  knowledge   of 


258  Insomnia  and  its   Therapeutics, 

the  whole  treatment  of  typhus  fever  is  essential,  if  one  would 
successfully  grapple  with  its  insomnia.  Some  points  in  gen- 
eral treatment  must  therefore  be  first  referred  to,  as  demand- 
ing careful  study. 

It  must  be  directed  to  the  conservation  of  strength,  and  to 
the  prevention  of  complications,  until  the  natural  crisis  of  the 
disease  is  reached.  It  may  be  considered  under  three  head- 
ings: The  maintenance  of  the  patient's  strength;  the  promo- 
tion of  the  excretion  of  the  poison;  the  alleviation  of  symp- 
toms. 

1.  The  Maintenance  of  the  Patient's  Strength. — This  en- 
tails that  the  surroundings  should  be  comfortable.  It  is 
important  that  the  bed  mattress  should  be  firm,  and  at  the 
same  time  yielding,  and  the  bed  clothes  light  and  cool ;  the 
bedroom  quiet,  moderately  lighted,  and  free  from  all  external 
disturbances.  It  must  be  thoroughly  ventilated  and  free 
from  draughts,  which  occasionally  cause  bronchitis  and  like 
complications. 

An  efficient  nurse  is  indispensable  for  typhus  fever,  and 
under  no  circumstances  can  she  display  her  abilities  more  con- 
spicuously. Thinking  and  acting,  it  may  be  absolutely  for  the 
patient  himself,  she  notes  all  things — things  that  in  them- 
selves are  the  veriest  trifles.  His  wants  she  not  alone  notes, 
tut  she  anticipates  them. 

With  regard  to  sleep  she  notices  its  absence,  presence,  and 
duration;  if  it  is  restless  or  disturbed  by  dreams  or  sleep- 
talking;  or  if  there  is  delirium,  she  observes  what  its  charac- 
teristics are. 

Food. — While  this  is  of  the  first  importance  independent^', 
it  is  a  far  more  frequent  source  of  sleeplessness  than  is  sup- 
posed. All  overfeeding  must  be  avoided.  Milk,  for  example, 
should  not,  in  the  early  days  when  thirst  is  still  urgent,  be 
given  to  assuage  it.  Food,  in  short,  should  be  managed  judi- 
ciously, and  with  direct  reference  to  the  digestive  powers. 

Stimulant.— it  is  seldom  required  by  the  young.  Admin- 
istered in  limited  quantity  in  severe  cases,  and  in  those  occur- 
ring in  patients  beyond  middle  life,  it  promotes  appetite,  and 
improves  digestion  and  assimilation,  controls  muttering  de- 
lirium, and  induces  sleep.  That  it  always  influences  delirium 
favorably  is  doubtful.  It  must  be  given  prudently,  and  the 
quantity  determined  in  each  individual  case;  for  in  typhus  as 


Insomnia  and  its   Therapeutics.  259 

in  health,  the  effects  of  alcohol  upon  the  system  vary  very 
remarkably.  Its  administration  must  be  guided  by  the  state 
of  the  pulse,  heart,  temperature,  and  tongue,  as  well  as  by  the 
amount  of  sleep.  It  must  be  cautiously  prescribed  when  the 
kidneys  are  not  excreting  well. 

2.  Excretion  of  the  Poison. — The  solution  and  elimination 
of  the  excessive  quantity  of  urea  is  accomplished  by  diluents, 
the  best  of  which  is  plain  water  without  stint.    Among  others 
suitable  may  be  mentioned,  ice,  soda  or  potash  water,  lemon- 
ade, barley,  rice,  or  toast  water;  whey;  lemon  or  orange  juice 
and  water;  all  of  which  may  be  iced  if  the  patient  prefer  it. 
A  sharp  distinction  must  be  drawn  between  diluent  and  food. 

3.  Alleviation  of  Symptoms. — Many  symptoms  may  arise 
in  the  course  of  the  disease  which,  of  themselves,  may  cause 
sleeplessness.     Their  palliation  is  therefore  highly  desirable. 
For  instance,  an  unusually  high  temperature  may  disturb 
sleep  unduly.     This  calls  for  the  administration  of  antipjrre- 
tics,  for  although  these  are  unable  to  shorten  in  the  slightest 
degree  the  duration  of  the  fever,  they  are  occasionally  capa- 
ble of  controlling  in  some  measure  the  excessive  metamorpho- 
sis, and  in  that  way  permitting  of  sleep.    Many  antipyretics 
possess  decided  hypnotic  properties.     Again,  symptoms  like 
cough  may  act  in  an  equally  perturbing  manner,  and  these 
require  suitable  treatment  for  their  relief. 

Sleeplessness  in  the  early  days  of  typhus  frequently  de- 
pends upon,  or  is  associated  with,  headache,  and  remedies 
which  relieve  the  latter  alleviate  the  former.  It  is  not  infre- 
quently relieved  by  fomenting  the  head  with  water,  as  hot  as 
it  can  be  borne,  as  recommended  by  the  late  Dr.  Graves  of 
Dublin.  Douching  the  head  with  warm  water  while  the  pa- 
tient leans  over  the  side  of  the  bed  suits  well.  In  some  cases 
more  comfort  is  experienced  from  the  use  of  tepid  or  cold  ap- 
plications, and  in  a  few  instances  leeches  to  the  temples  are 
required. 

If  the  headache  does  not  yield  and  sleep  return,  chloral  hy- 
drate should  be  given  in  20-grain  doses,  as  recommended  by 
Dr.  Russell,  of  Glasgow,  and  repeated  in  three  hours  if  required. 
Dr.  Russell  urged  in  its  favor  that  the  patient  could  be  readily 
roused  to  clear  his  bronchial  tubes,  or  to  take  food,  and  then 
fall  asleep  again.  Sound  sleep  relieves  headache;  on  the  con- 
trary, sleeplessness  aggravates  it. 


260  Insomnia  and  its   Therapeutics. 

Chloral  hydrate  is  suitable  in  the  early  part  of  the  disease 
when  there  is  suffusion  of  the  eyes  and  high  arterial  tension. 
When  headache  and  sleeplessness  are  replaced  by  delirium 
and  disturbed  sleep,  chloral  hydrate  is  still  the  best  hpynotic 
so  long,  as  the  patient's  strength  remains  good;  but  when  the 
heart  grows  feeble,  and  perhaps  irregular,  its  use  is  contra- 
indicated.  Opium,  or  its  alkaloid  morphine,  is  then  the  better 
medicant.  An  injection  of  morphine  with  atropine  about  8  or 
9  P.M.  suits  well. 

Dr.  Graves  was  in  the  habit  of  giving  tartar  emetic  with 
the  opium  when  the  delirium  was  unduly  violent,  and  when 
the  fever  was  unusually  high,  the  amount  being  increased  or 
decreased  as  these  complications  seemed  to  require.  His  or- 
dinary prescription  was  as  follows : 

3  Tinct.  opii, 3  i. 

Antim.  tart., gr.  iv. 

Mist,  camphor., 3  viij. 

Sig.  Take  a  tablespoonful  every  two  hours  until  sleep  is 
induced. 

Dr.  Murchison  recommended  digitalis  in  place  of  antimony 
as  a  vascular  sedative,  and  as  an  aid  to  elimination  through 
the  kidneys  instead  of  through  the  skin. 

]J  Liq.  opii  sed., 3  i. 

Tinct.  digital., 3  i. 

Spt.  eth.  nit.,          .        .        .        .        .        .    3  ij. 

Aq.  camph., ad  3  vi. 

M.  Sig.  Take  two  tablespoonfuls  at  once,  and  a  table- 
spoonful  every  two  hours  until  sleep  is  induced. 

In  delirium  resembling  that  of  delirium  tremens  Dr.  Mur- 
chison advocated  the  addition  of  IT],  xx.  of  sulphuric  ether  to 
each  dose  of  the  digitalis  mixture,  or  a  pill  containing  half  a 
grain  of  opium  with  three  grains  of  camphor. 

It  is  occasionally  a  very  difficult  task  to  decide  whether  or 
not  to  prescribe  an  opiate;  from  the  knowledge,  on  the  one 
hand,  that  the  patient  will  die  unless  he  get  sleep,  and  on  the 
other,  that  his  suffused  eyes  and  pin-hole  pupils  render  it  pos- 
sible that  fatal  coma  may  follow  the  administration  of  the 
narcotic.  In  the  majority  of  cases  it  is  wisest  to  undertake 


Insomnia  and  its   Therapeutics.  261 

the  risk.  Dr.  Murchison  thought  that  opium  was  much  more 
dreaded  than  it  ought  to  be. 

The  use  of  opium  is  contra-indicated  when  there  is  vaso- 
motor  paralysis,  extreme  contraction  of  the  pupils,  bronchial 
or  pulmonary  affections,  or  any  tendency  to  coma,  or  to  sup- 
pression of  urine.  Belladonna,  cannabis  indica,  and  henbane 
have  all  been  tried,  and  have  found  many  warm  advocates. 
Camphor,  musk,  sulphuric. ether,  and  turpentine,  are  all  useful 
remedies  in  weakened  states. 

In  the  insomnia  of  convalescence  quinine  and  strychnine 
hold  the  first  places.  Careful  diet,  and  the  judicious  use  of 
malt  liquors  and  change  of  air,  are  powerful  adjuncts  to  treat- 
ment. Opium  should  be  avoided,  tending  as  it  does  to  de- 
range the  secretions. 

Enteric  Fever. — This  fever  comes  on  insidiously  and  the 
patient  may  not  be  compelled  to  take  to  bed  until  six  or  eight 
days  have  elapsed.  Its  incursion  is  evidenced  by  chilliness 
and  shivering,  muscular  and  articular  pain,  malaise,  headache, 
depression,  and  sleeplessness. 

Toward  the  end  of  the  first  week  the  headache  subsides, 
and  the  sleeplessness  is  associated  with  restlessness  and  mild 
delirium,  or  with  hallucinations  or  violent  delirium.  If  the 
patient  does  sleep  he  is  disturbed  by  dreams.  Still  later, 
there  may  be  somnolence,  the  sufferer  lying  for  days  without 
taking  any  notice  of  his  surroundings  or  asking  for  food,  and 
often  neglecting  even  the  calls  of  nature. 

The  chief  features  of  the  disease  are,  a  somewhat  quick- 
ened pulse,  at  first  of  increased  tension  but  subsequently  soft 
and  compressible,  and  as  the  heart  gets  weakened,  dicrotic ; 
an  increased  temperature;  scanty  urine  containing  a  large 
excess  of  urea;  diarrhoea  of  a  characteristic  kind. 

In  enteric  fever  there  is  even  less  vascularity  of  the  brain 
and  membranes  found  after  death  than  in  typhus.  Dr.  Mur- 
chison summed  up  thus :  "  It  was  clearly  shown  by  Louis  and 
Chomel  that  the  morbid  appearances  found  in  the  brain  and 
its  membranes  in  enteric  fever  were  equally  common  after 
death  from  other  acute  diseases,  especially  pneumonia,  and 
that  no  relation  existed  between  them  and  the  intensity  of 
the  cerebral  symptoms."  Here  again  we  must  attribute  the 
sleeplessness  and  other  nervous  symptoms  to  mal-nutrition  of 
the  nervous  textures. 


262  Insomnia  and  its  Therapeutics. 

Treatment. — The  remarks  made  upon  the  maintenance  of 
the  general  strength  and  the  excretion  of  the  poison  in  connec- 
tion with  typhus  fever,  apply  with  equal  force  here.  It  may, 
however,  be  emphasised  that  the  food  must  be  free  from  solid 
particles  of  all  kinds,  and  that  all  indiscretions  in  diet  are 
apt  to  cause  sleeplessness.  The  mitigation  of  all  unfavorable 
symptoms  is  usually  conducive  to  sleep.  Diarrhoea,  distention 
of  the  bowels  with  gas,  cough,  and  other  symptoms  must  be 
treated,  and  abnormally  high  temperature  controlled. 

For  many  years  the  writer  has  treated  all  his  cases,  with 
a  few  exceptions,  from  the  start  to  the  termination,  with  the 
following  pills. 

5  Pulv.  digital.,       .        .        .        .        .        .  gr.  ss. 

Sulph.  quinin., gr.  ij. 

Ext.  opii, .  gr.  £. 

Pulv.  ipecac., gr.  \. 

Ft.  pil.  i.     Sig.  One  every  four  hours. 

He  increases  or  decreases  the  dose  of  the  opium  and  digi- 
talis, the  former  in  reference  to  diarrhoea  and  sleep,  and  the 
latter  to  the  state  of  the  pulse  and  heart.  He  has  had  little 
trouble  wifh  sleeplessness.  When  the  temperature  rose  to 
an  abnormal  height  decisive  measures  were  adopted  for  its 
control. 

Sleeplessness  should  be  treated  upon  the  same  lines  as  that 
of  typhus.  The  writer  has  seldom  required  to  resort  to  the 
use  of  special  remedies,  alcohol  being  usually  sufficient  to  in- 
duce sleep.  When  a  hypnotic  is  needed,  he  gives  chloral  in 
the  early  stages  and  opium  in  the  later,  combining  potassium 
bromide  with  the  former  and  antimony  with  the  latter  if  the 
delirium  be  violent.  He  is  satisfied  that  the  injurious  effects 
which  are  supposed  to  attend  the  administration  of  opium  in 
this  disease  are  over-rated ;  although  when  great  prostration 
of  the  heart  is  present  both  opium  and  chloral  are  best  avoided, 
and  camphor  and  sulphuric  ether  used  instead.  He  has  got 
good  results  from  the  use  of  paraldehyde  in  45-minim  and 
urethane  in  25-grain  doses.  In  some  instances,  where  death 
seemed  to  be  imminent,  sulphuric  ether,  subcutaneously  in- 
jected, induced  sleep  and  saved  life. 

It  does  not  seem  needful  to  pursue  this  subject  further,  as 


Insomnia  and  its   Therapeutics.  263 

the  sleeplessness  which  accompanies  influenza  and  relapsing1 
fever,  puerperal  septicaemia  and  erysipelas,  etc.,  requires  to 
be  treated  upon  the  same  principles. 

Measles. — This  is  a  febrile  disease  ushered  in  somewhat 
gradually  with  rigors,  frontal  headache,  malaise,  vomiting, 
and  severe  catarrh  of  the  eyes  and  nostrils,  with  intolerance 
of  light.  In  children  convulsions  may  announce  the  invasion. 
Sleeplessness  is  present  from  the  first,  and  may  be  accom- 
panied by  mild  delirium.  The  fever  quickly  rises  till  it  reaches 
103°  or  perhaps  104°  Fahr.,  very  rarely  higher;  a  high  tem- 
perature indicating  a  severe  attack,  or  the  occurrence  of  com- 
plications. It  usualty  subsides  somewhat  suddenly.  The  pulse 
is  quick;  in  children,  very  rapid.  The  complications  met  with 
are  chiefly  bronchitis,  pneumonia,  pleurisy,  pericarditis,  diar- 
rhoea, and  ophthalmia. 

Treatment. — Attention  must  be  paid  to  the  patient's  sur- 
roundings and  feeding,  and  to  the  alleviation  of  symptoms, 
etc.  Sleeplessness,  headache,  and  increased  body-temperature 
are  best  treated  by  warm  or  tepid  water  douching-  to  the  head, 
and  by  the  blanket  bath,  which  is  simply  a  pack  in  which  a 
blanket  wrung  out  of  hot  water  is  substituted  for  a  cold  wet 
sheet.  A  warm  bath  at  night  and  a  tepid  one  in  the  morning 
conduce  to  sleep,  and  to  the  comfort  of  the  patient.  A  mixture 
of  aconite,  ipecacuanha,  and  Mindererus'  spirit,  mitigates  the 
catarrhal  symptoms,  and  moderates  the  temperature.  Should 
a  hypnotic  be  required,  chloral  hydrate  may  be  given  in  doses 
of  one  grain  for  each  year  of  age  up  till  ten  or  twelve  years. 
Opium  is  best  avoided. 

The  sleeplessness  of  rotheln  and  of  varicella  may  be  simi- 
larly managed. 

Scarlet  Fever. — A  few  words  will  suffice,  in  addition  to 
what  has  already  been  written,  to  indicate  the  treatment  of 
sleeplessness  in  connection  with  scarlet  fever;  the  shortest  of 
the  exanthemata,  as  it  is  the  most  variable.  It  is  character- 
ized mainly  by  high  temperature  (104°  or  105°  Fahr.)  and  an 
excessively  rapid  pulse,  with  redness,  soreness,  and  occasion- 
ally ulceration  of  the  throat.  The  temperature  usually  sub- 
sides gradually. 

The  complications  which  mostly  disturb  sleep  are,  vomit- 
ing, which  is  best  treated  with  an  emetic,  and  afterward  with 
hydrocyanic  acid  in  an  effervescing  saline;  coryza,  which 


1264  Insomnia  and  its   Therapeutics. 

yields  to  the  injection  of  a  weak  solution  of  nitrate  of  silver 
(gr.  iv.  to  §  i.)  into  the  nasal  cavities;  soreness  and  ulceration 
of  the  throat,  which  must  be  actively  attended  to,  as  also 
the  earliest  symptoms  of  inflammation  of  the  middle  ear.  Ice 
applied  externally  and  frequently  swallowed  is  a  useful  remedy 
in  those  circumstances. 

Salivation  is  sometimes  a  troublesome  symptom,  and  the 
greatest  care  must  be  taken  to  remove  the  tenacious  secretion 
as  often  as  possible.  No  hypnotic  is  admissible  under  such 
conditions. 

Treatment. — Headache  yields  to  douching-  with  either  warm 
or  tepid  water;  rheumatic  pains  require  opium,  and  the  best 
form  is  Dover's  powder,  but  it  must  be  carefully  prescribed  in 
the  case  of  children.  The  temperature  must  be  controlled, 
this  being"  often  accomplished  by  means  of  the  wet  pack  re- 
peated twice  a  day,  which  also  conduces  to  sleep.  When  rest- 
lessness is  pronounced,  tincture  of  aconite  may  be  given  at 
hourly  intervals,  in  minute  doses,  its  effects  being-  closely 
watched.  Quinine  is  likewise  serviceable  in  doses  of  one  grain 
for  each  year  of  age  up  till  ten  years,  and  may  be  given  either 
alone  or  with  a  small  dose  of  digitalis.  Antipyrine  answers 
well  in  similar  doses  given  every  three  or  four  hours.  The 
writer  thinks  that  antipyrine  answers  better  in  the  course  of 
the  disease  than  at  its  onset. 

Restlessness  during-  the  night,  when  the  skin  is  hot  and 
pung-ent,  may  be  alleviated  by  the  free  inunction  of  cocoa-nut 
oil.  Sleeplessness  is  likewise  modified  by  anointing-  the  head 
freely  with  oil,  and  this  should  be  tried  whenever  the  hair  is 
not  too  abundant.  These  remedies  will  usually  serAre  to  pro- 
mote sleep,  but  when  they  fail  chloral  hydrate  must  be  cau- 
tiously given.  Alcoholic  stimulant  and  carbonate  of  ammonia 
are  sometimes  useful  in  advanced  stages. 

In  very  enfeebled  states,  both  in  scarlet  fever  and  in  diph- 
theria, the  patient  may  lapse  into  a  drowsj^  condition.  When 
this  occurs  he  should  be  roused  frequently  to  take  nourish- 
ment. 

In  the  sleeplessness  of  diphtheria  chloral  hydrate  and 
opium  must  be  dispensed  with. 

In  small-pox  insomnia  is  frequently  a  persistent  symptom; 
chloral  hydrate  and  opium  are  then  called  for.  Salivation 
requires  careful  watching.  The  free  inunction  of  oil,  impreg- 


Insomnia  and  its   TJierapeutics.  265 

nated  with  camphor  or  carbolic  acid,  is  always  soothing"  to  the 
skin,  and  sometimes  induces  sleep. 

Acute  Rheumatism. — Whatever  may  be  the  real  pathol- 
ogy of  acute  rheumatism,  it  resembles  the  continued  fevers  in 
many  important  respects.  After  a  premonitory  stage,  in 
which  sleeplessness  is  a  characteristic  symptom,  it  is  ushered 
in  by  chill,  followed  by  rise  of  temperature,  quickened  pulse, 
and  the  usual  symptoms  of  fever.  Its  main  features  are  pro- 
fuse sweats,  not  critical,  having-  the  odor  of  sour  milk;  pain 
in  the  joints,  greatly  aggravated  by  movement  and  pressure, 
and  accompanied  by  swelling-.  It  may  affect  most  of  the 
joints  simultaneously  or  in  succession,  often  progressing-  by 
metastasis,  and  frequently  attacking-  the  fibrous  textures  of 
the  cardiac  valves  or  endocardial  or  pericardial  membranes. 
It  impresses  the  nervous  system,  causing-  restlessness  and 
sleeplessness  throughout  all  its  stages,  and  occasionallj'  in 
convalescence.  Sometimes'  slight  delirium  is  observed,  and 
also  hyperpyrexia. 

There  are  many  complications,  such  as  embolism  of  the 
brain,  spleen,  lungs,  and  kidnej'S,  as  well  as  pneumonia,  pleu- 
risy, etc. 

Treatment. — This  must  be  conducted  upon  the  general 
principles  laid  down  in  discussing  that  of  t3'phus  fever.  The 
diet,  however,  must  be,  as  far  as  possible,  free  from  meat 
soups.  Alkaline  effervescing  water  should  be  drunk  copiously. 
The  patient  should  be  clothed  in  a  flannel  night-dress,  and  lie 
between  blankets.  Purgatives  must  be  avoided  as  much  as 
possible,  as  movements  aggravate  the  distress.  The  salicyl- 
ates  are  curative  beyond  the  relief  they  give  to  pain/and  they 
promote  sleep  out  of  proportion  to  the  reduction  of  tempera- 
ture that  they  effect.  Salicin  or  the  salicylate  of  soda  in  20- 
grain  doses  should  be  given  every  afternoon  at  hourly  inter- 
vals, for  four  or  six  times.  The  joints  must  be  wrapped  up 
in  cotton  wool,  and  supported  so  as  to  be  maintained  at  rest. 
Anodynes,  such  as  menthol  liniment,  chloroform  and  bella- 
donna liniments  in  equal  parts,  or  alkaline  lotions  (e.g.,  1J 
loci  id.  potass.,  3  ij.,  Bicarb,  sodii,  3  vi.,  Liq.  morph.  acet.,  3  i., 
Aq.,  ad  3  xij.),  are  useful ;  or  fomentations  with  a  saturated  solu- 
tion of  washing  soda. 

Antipyrine  affords  excellent  results,  relieving  pain,  lower- 
ing temperature,  inducing  sleep,  and  apparently  curing  the 


266  Insomnia  and  its   Therapeutics. 

disease.  When  hyperpyrexia  occurs  it  must  be  treated  actively 
by  baths  rapidly  cooled. 

If  sleeplessness  persist  either  as  an  individual  symptom 
or  as  the  result  of  pain,  opium  must  be  resorted  to  in  the 
form  of  Dover's  powder,  or  the  subcutaneous  injection  of  mor- 
phine, at  bedtime.  In  convalescence,  before  the  cerebral  cells 
have  recovered  their  tone,  sleeplessness  is  best  combated  by 
quinine  in  IQrgrain  doses  at  bedtime,  followed  by  whiskey  or 
brandy  in  hot  water.  Warburg's  tincture  in  3  ss.  doses  serves 
the  same  purpose.  Endocarditis  and  pericarditis  occurring1 
in  the  course  of  this  disease  require  the  same  treatment  as 
the  disease  itself. 

In  sleeplessness  which  occasionally  attends  chronic  rheu- 
matism ten  minims  of  the  oil  of  wintergreen  three  times  a 
day,  the  last  dose  at  bedtime,  is  sometimes  very  efficacious. 
The  use  of  sulphur  in  such  cases  should  not  be  forgotten. 

Rickets. — It  is  a  common  occurrence  to  be  consulted  about 
a  child  who  is  said  to  be  restless  and  sleepless  at  night,  and 
who  spends  a  considerable  portion  of  every  twenty-four  hours 
in  crying,  deriving"  no  solace  from  its  nurse's  efforts  to  soothe 
and  amuse  it,  and  this  when  it  is  believed  to  be  in  good  health. 

Such  S3rmptoms  very  often  depend  upon  rickets,  although 
they  by  no  means  enter  into  the  history  of  ever3r  example  of 
the  disease.  On  the  contrary,  many  children  who  suffer  se- 
verely from  it  present  no  such  noisy  symptoms,  but  sit  quietly 
and  peacefully  throughout  the  whole  day  if  they  be  left  un- 
disturbed. Inquiry  discloses  a  history  of  slight  fever,  disor- 
dered evacuations,  variable  appetite,  and  loss  of  flesh ;  and  that 
the  child  from  being-  good-tempered  and  happy  has  become 
peevish  and  fretful,  crying1  upon  the  least  provocation  or  with- 
out it.  Pushing1  the  examination  further,  evidence  of  the  dis- 
ease is  abundantly  obtained. 

During  sleep  three  characteristic  symptoms  are  noticed: 
that  the  child  is  restless  and  uneasy,  and  tosses  off  the  bed- 
clothes, preferring  to  lie  naked  even  in  cold  weather;  that  it 
sweats  profusely  about  the  head,  neck,  and  chest;  and  that 
its  decubitus  may  be  altered,  the  forehead  being  buried  in  the 
pillow,  and  the  body  supported  on  the  elbows  and  knees. 
During  sleep  the  veins  of  the  head  and  neck  are  seen  to  be 
distended,  while  the  carotid  arteries  throb  and  heave  in  a  very 
marked  way.  Sleeplessness  depends  upon  irritability  of  the 


Insomnia  and  its   Therapeutics.  267 

cerebral  cells,  and  upon  an  enfeebled  state  of  the  nervous  sys- 
tem from  defective  nourishment.  This  impaired  nutrition  is 
further  evidenced  in  emaciation,  late  dentition,  and  backward- 
ness in  talking-  and  walking. 

The  subjects  of  rickets  are  liable  to  suffer  from  night  ter- 
rors, laryngismus  stridulus,  and  spurious  croup,  and  are  apt 
to  have  their  slumbers  further  disturbed  by  these  causes. 

Treatment. — The  dwelling-  and  surroundings  are  impor- 
tant. The  drainage  and  ventilation  of  the  house  ought  to  be 
as  perfect  as  possible.  The  day  room  should  preferably  have 
a  southern  aspect;  the  bedroom  a  temperature  maintained  at 
about  60°  Fahr.,  and  the  mattress  and  pillow  made  of  firm 
hair.  Dr.  West  suggested  that  the  latter  should  have  a  hole 
in  the  centre  to  relieve  the  occiput  from  pressure,  which  he 
stated  greatly  improved  sleep.  In  many  cases  this  is  a  com- 
fort, as  rickety  children  rub  all  the  hair  off  the  back  of  the 
head  through  rolling  it  uneasily  from  side  to  side.  The  clothes 
may  be  tied  to  the  corners  of  the  bed  to  prevent  them  being 
tossed  off,  as  these  children  are  very  liable  to  catarrhal  affec- 
tions. A  morning  salt  bath,  cold  or  tepid,  followed  by  gentle 
rubbing,  a  considerable  portion  of  every  day  spent  in  the  open 
air,  and  a  change  to  the  country  or  seaside,  are  all  most  de- 
sirable adjuncts  to  treatment.  During  the  first  six  months 
of  age  the  food  should  be  restricted  solely  to  milk,  and  if  re- 
course be  had  to  cows'  milk,  that  of  the  Alderney  is  to  be  pre- 
ferred. It  should  be  boiled  for  a  minute,  and  mixed  with  a 
fourth  part  of  lime  water.  Between  eight  and  fourteen 
months,  oatmeal  gruel  or  other  farinaceous  food  may  be 
added  to  the  milk.  After  that  time  very  weak  meat  soup, 
made  of  beef,  mutton,  or  chicken,  with  a  little  cream,  is  allow- 
able. Thin  bread  and  butter  sprinkled  with  brown  sugar  often 
agrees  well.  Raw  meat  pounded  and  eaten  as  a  sandwich, 
gravy  and  potatoes,  the  yolk  of  a  boiled  egg,  are  all  suitable. 
Digestion  may  be  aided  by  malt  extracts,  which  agree  also 
when  they  are  mixed  with  small  quantities  of  cod-liver  oil. 
Diarrhoea  yields  to  the  administration  of  the  salicylates  of  bis- 
muth or  magnesia,  in  doses  of  from  gr.  ij.  to  v.,  after  the  tract 
has  been  cleared  with  rhubarb  and  soda.  Tonics  are  usually 
required;  steel  wine,  Parrish's  syrup,  small  doses  of  quinine, 
strychnine  with  an  acid,  are  all  useful.  The  writer  has  got 
very  good  results  from  the  syrup  of  lactophosphate  of  lime 
and  iron. 


268  Insomnia  and  its  Therapeutics. 

Sleeplessness  is  generally  remedied  by  sponging  the  pa- 
tient's bod}7  at  bedtime  with  warm  vinegar  and  water,  or  with 
equal  parts  of  olive  oil  and  whiskey,  and  by  a  dose  of  quinine, 
varying  from  one  to  three  grains.  It  is  best  given  in  milk. 
Opiates  are  extremely  injurious. 

It  ma}7  not  be  out  of  place  here  to  advert  to  a  good  rule  in 
medical  practice,  to  strip  completely  every  child  that  cries 
without  apparent  cause,  for  the  explanation  will  frequently 
be  found  in  some  obnoxious  article  torturing  it. 

Syphilis. — Inherited.  This  disease  presents  in  the  infant 
some  symptoms  analogous  to  those  met  with  in  rickets,  e.g., 
violent  and  persistent  fits  of  crying  by  day,  and  restlessness 
and  sleeplessness  at  night.  It  is  to  be  similarly  explained — 
the  cerebral  cells  are  starved. 

If  the  child  has  been  born  free  from  the  usual  characteris- 
tic appearances  of  the  disease,  these  will  manifest  themselves 
during  the  first  six  weeks.  The  chief  are,  congestion  of  the 
mucous  membrane  of  the  eyes  and  nasal  cavities,  causing 
well-marked  coryza  and  snuffles,  the  latter  interfering  with 
the  respiration.  The  appearance  alters  greatly.  They  be- 
come puny  and  aged-looking,  with  a  muddy  unhealthy  com- 
plexion. A  coppery  rash  appears  on  the  hands,  feet,  genitals, 
perineum,  and  abdomen;  ecthymatous  eruptions  are  found 
here  and  there  over  the  body ;  and  mucous  tubercles  round 
the  anus,  and  fissures  at  the  angles  of  the  mouth  and  nostrils. 
Loss  of  hair,  hoarseness  and  huskiness  of  the  voice,  are  noticed, 
and  if  the  thymus  gland  be  enlarged,  there  may  be  attacks  of 
laryngismus  stridulus.  Further,  there  is  loss  of  flesh;  and 
when  the  teeth  appear  they  are  pegged. 

Treatment. — This  involves  the  treatment  of  the  disease,  no 
hypnotic  being  of  any  service.  Equal  parts  of  mercurial  oint- 
ment and  lanolin  may  be  applied  to  the  abdomen,  and  covered 
up  with  a  flannel  bandage,  or  small  doses  of  gray  powder 
given  several  times  a  day.  Considerable  relief  is  often  af- 
forded by  local  applications  to  the  nostrils.  The  diet  and 
regimen  must  be  carefully  attended  to. 

Syphilis. — Acquired.  In  the  early  history  of  secondary 
syphilis  sleeplessness  may  depend  upon  the  general  febrile 
symptoms,  and  upon  pain  in  different  parts  of  the  body.  It 
is  not  to  this  form  of  insomnia  that  we  wish  to  refer,  as  its 
association  is  perfectly  evident. 


Insomnia  and  its   Therapeutics.  269 

There  is  a  second  class  of  cases  associated  with  syphilis, 
which  depend  chiefly  upon  severe  headache  and  obscure  pains 
in  the  bones  (particularly  the  clavicles),  and  also  in  the  joints, 
resembling-  rheumatic  pains,  which  tend  to  grow  worse  at 
night  and  to  disappear  during-  the  day.  Such  cases  will  obvi- 
ously be  traced  to  their  proper  origin. 

There  is  yet  a  third  group  of  cases,  which  are  much  more 
obscure,  and  are  characterized  by  insomnia,  nightly  recurring 
at  a  certain  hour,  when  without  pain  or  discomfort,  or  any 
apparent  reason  to  account  for  it,  the  patient  practically  re- 
mains wide  awake  till  the  morning.  The  usual  time  for  awak- 
ing is  about  two  or  three  A.M.  These  cases  present  difficulties, 
for  they  are  sometimes  associated  with  dyspeptic  derange- 
ments, and  symptoms  of  anaemia  and  neurasthenia.  The 
sleeplessness  is  never  by  any  chance  connected  by  the  patient 
with  the  malady  from  which  he  has  suffered,  consequently  he 
does  not  mention  the  circumstance  at  all;  and  as  it  sometimes 
happens  in  private  practice  that  reasons  exist  for  concealing 
the  truth,  the  suggestion  of  syphilis  by  the  practitioner  may 
be  repudiated. 

This  symptom  may  occur  in  either  sex,  and  in  any  tempera- 
ment, but  it  seems  probable  that  it  is  more  frequently  met 
with  in  those  of  neurotic  temperament,  and  particularly  in  the 
neurasthenics  just  mentioned.  It  is  peculiar  in  this  respect, 
that  it  3'ields  only  to  constitutional  treatment.  There  is  no 
reason  to  doubt  that  sleeplessness  is  due  to  a  cachectic  condi- 
tion, inducing  an  irritable  and  unstable  state  of  the  cerebral 
cells.  Frequently  the  sole  guide  one  has  in  these  cases  is  the 
evidence  to  be  obtained  from  old  scars  or  lesions  which  tell 
their  own  tale.  Some  time  agp  the  writer  was  consulted  by  a 
gentleman  for  loss  of  sleep,  who  presented  the  appearance  of 
one  who  had  long  suffered  from  bad  health,  though  he  as- 
serted it  was  not  so.  Upon  looking  at  his  tongue  a  small 
lump  the  size  of  a  small  hazel-nut  was  observed  toward  its 
centre,  and  no  remark  being  made  he  was  put  upon  specific 
remedies,  when  the  tumor  and  the  insomnia  disappeared 
simultaneously.  These  patients  have  a  cachectic  appearance, 
with  muddy  and  earthy  complexions;  symptoms  which  should 
always  arouse  the  suspicion  of  the  disease. 

Treatment. — Mercury  in  one  or  other  of  its  various  forms 
is  to  be  prescribed,  such  as  a  calomel  vapor  bath,  the  inunc- 


270  Insomnia  and  its  Therapeutics. 

tion  of  the  oleate  with  lanolin  into  the  groins  or  armpits,  or 
the  green  iodide  by  the  mouth.  One  of  these  combined  with 
the  free  use  of  the  iodide  of  potassium  will  speedily  relieve  the 
insomnia.  As  a  rule,  the  iodide  alone  is  not  sufficient;  mer- 
cury is  the  remedy.  Tonics,  such  as  iron  and  arsenic,  and 
cod-liver  oil,  with  increased  nourishment,  will  probably  be 
called  tor;  while  Turkish  baths,  wet  packs,  and  change  of  air 
will  expedite"  the  cure. 

Cachexice. — Insomnia  due  to  this  cause  is  closely  allied  to 
that  depending  upon  syphilitic  poison.  The  altered  condition 
of  blood  leads  to  a  perverted  nutrition  of  the  nervous  centres, 
peculiarly  favorable  to  insomnia.  It  is  met  with  in  those  who 
have  either  suffered  from  well-marked  malarious  fevers,  or  in 
those  who  have  lived  in  malarious  districts  without  having 
had  fever.  It  comes  on  at  two  or  three  in  the  morning  with 
provoking  punctuality,  and  persists  until  almost  the  hour  for 
rising,  leading  to  great  mental  and  physical  exhaustion.  Dur- 
ing the  day  patients  complain  of  this  exhaustion,  and  give 
evidence  of  it  in  increased  irritability  and  depression;  but  if  we 
except  a  h3Tpersensitiveness  to  cold,  they  exhibit  no  symptom 
pointing  to  malaria,  and  certainly  they  do  not  attribute  their 
sleeplessness  to  that  cause.  Some  present  a  cachectic  appear- 
ance, which  affords  a  clue  to  the  source.  The  writer  has  met 
with  this  form  of  insomnia  more  frequently  in  children  than 
in  adults.  They  have  usually  presented  a  pasty  and  un- 
healthy physiognomy. 

Treatment. — This  consists  in  the  nightly  administration  of 
quinine,  a  grain  for  every  year  of  age  up  to  twenty  years. 
Warburg's  tincture  in  f  ss.  doses  for  adults  is  also  efficacious. 
During  the  day  arsenic  should  be  given  after  meals.  Massage, 
change  of  air  to  the  seaside,  and  nourishing  and  stimulating 
diet,  are  all  beneficial  auxiliaries.  Opiates  are  very  unsuitable. 


CHAPTER   XV. 

INSOMNIA  DEPENDING  UPON  AFFECTIONS  OF  THE 
URINARY  SYSTEM. 

MANY  diseases  of  the  urinary  organs  give  rise  to  disturbed 
sleep,  and  the  want  of  sleep  frequently  becomes  a  troublesome 
and  aggravating  symptom.  We  cannot  attempt  in  this  work 
to  discuss  these  diseases  or  their  therapeutics.  A  few  words 
must  suffice  to  indicate  the  importance  of  the  subject. 

Sleeplessness  in  these  ailments  is  mainly  due  to  irritability 
of  the  bladder,  which  arises  from  many  and  diverse  causes. 

The  irritability  may  depend  upon  an  increased  secretion 
of  urine  at  night  as  well  as  during  the  day.  Such  a  flow 
should  always  excite  suspicion,  particularly  if  no  considerable 
amount  of  liquid  is  imbibed  before  going  to  bed.  For  it  must 
be  remembered  that  the  quantity  of  urine  secreted  during 
sleep  is  greatly  diminished,  and  there  is  therefore  so  much 
the  less  occasion  to  expel  the  amount  which  has  accumulated. 

Irritability  of  the  bladder,  dependent  upon  an  abundant 
increase  in  the  quantity  of  urine  secreted,  is  met  with  in  the 
following  diseases. 

Diabetes  Mellitus. — Sleep  is  apt  to  be  broken  by  frequent 
calls  to  urinate,  and  to  appease  hunger  and  assuage  thirst. 
It  is  also  disturbed  by  eczematous  and  pruriginous  eruptions 
dependent  on  the  sugar  in  the  blood.  These  irritations,  like 
all  excitations  of  sensor}'  nerves,  are  attended  by  a  corre- 
sponding rise  in  the  arterial  tension,  which  disturbs  sleep. 
Such  patients  are  sometimes  kept  awake  by  pains  in  the  ex- 
tremities, neuralgic  in  character,  which  grow  worse  at  night 
in  bed.  Dr.  Pavy,  who  (with  others)  has  called  attention  to 
these  pains,  believes  they  are  due  to  peripheral  neuritis.  The 
writer  has  seen  deep  ulceration  of  the  heel  with  excruciating 
pain  occur  in  diabetes.  Twice  he  has  witnessed  most  agoniz- 
ing pain  in  the  shoulder  prelude  a  fatal  termination.  In  some 
respects  the  symptoms  approximate  to  those  of  locomotor 


272  Insomnia  and  its   Therapeutics. 

ataxy,  for  there  is  often  some  awkwardness  of  gait,  and  the 
knee-jerk  is  usually  lessened.  Sciatica  is  frequently  com- 
plained of.  Affections  of  the  skin,  such  as  boils,  carbuncles, 
erysipelas,  etc.,  may  perturb  sleep. 

Treatment. — Diet  is  of  the  first  importance.  Opium  and 
codeine  tend  in  the  direction  of  curing'  the  disease  and  pro- 
ducing sleep.  Antipyrine  and  antifebrine  have  a  decided  influ- 
ence over  the  pain  which  occurs  in  this  affection. 

Diabetes  Insipidus. — In  this  affection  sleep  is  chiefly  dis- 
turbed by  frequent  calls  to  urinate. 

Azoturia. — The  writer  has  met  with  this  ailment  mostly 
in  young  men  who  were  suffering  from  mental  emotion.  They 
complain  of  constant  and  teasing  inclination  to  pass  water, 
depending  apparently  upon  a  spasmodic  irritability  of  the 
neck  of  the  bladder.  This  is  usually  accompanied  by  a  train 
of  dyspeptic  symptoms,  and  a  marked  feeling  of  prostration 
and  inability  for  exertion.  Their  days  are  filled  with  mental 
weariness,  and  their  nights  with  restlessness.  The  urine  is 
generally  copious  (80  to  100  ounces),  having  a  specific  gravity 
ranging  from  1.030  to  1.040,  due  to  an  excessive  excretion  of 
urea,  and  being  quite  free  from  sugar. 

Treatment. — This  consists  in  removal  of  the  source  of 
worry  when  that  is  possible,  together  with  change  of  air  and 
scene;  nutritious  diet,  chiefry  composed  of  non-nitrogenous 
foods,  and  the  alleviation  of  dj^speptic  derangements.  Quinine 
and  strychnine  are  the  drugs  that  have  afforded  the  best  re- 
sults. Minim  doses  of  tincture  of  cantharides  have  on  one  or 
two  occasions  relieved  the  feelings  Of  strangury. 

Chronic  Diseases  of  the  Kidney. — In  the  later  stages  of 
these  diseases  there  is  irritability  of  the  bladder,  which  in- 
variably grows  worse  at  night,  and  is  associated  with  rest- 
lessness. The  attendant  symptoms  naturally  lead  to  the  cor- 
rect diagnosis  and  treatment  of  these  affections. 

Irritability  may  depend  upon  inflammatory  changes  in 
the  prostate  gland,  bladder,  and  ureters,  as  well  as  upon  or- 
ganic diseases  in  these  parts. 

Acute  Prostatitis. — This  is  mostly  met  with  in  young  sub- 
jects, particularly  of  gouty  habit,  as  the  result  of  gonorrhoeal 
and  other  inflammations.  Among  the  symptoms,  the  urgent 
and  constant  desire  to  pass  water  is  probably  the  most  dis- 
tressing. Relief  is  not  obtained  by  emptying  the  bladder,  and 


Insomnia  and  its  Therapeutics.  273 

a  trace  of  blood  not  infrequently  follows  urination.  Digital 
examination  is  sometimes  necessary  to  clear  up  the  diagnosis. 

Treatment. —  This  must  be  conducted  on  antiphlogistic 
principles.  Opium  or  cannabis  indica  are  required  to  alleviate 
the  pain. 

Chronic  Prostatitis. — In  this  the  symptoms  are  of  the 
same  description,  but  modified  in  degree.  They  are  always 
aggravated  during  the  night. 

Treatment. — Here  counter-irritation  has  a  large  field  of 
usefulness. 

Chronic  Hypertrophy  of  the  Prostate. — This  is  one  of  the 
troubles  of  advancing  years.  Many  such  patients  spend  their 
days  and  nights  in  constantly  relieving  the  bladder;  sleep  is 
consequently  much  curtailed.  The  act  of  micturition  is  usu- 
ally both  preceded  and  accompanied  by  pain.  Eventually  a 
catarrhal  condition  of  the  bladder  ensues,  the  urine  becoming 
ainmoniacal,  and  copiously  mixed  with  glutinous  ropy  mucus 
and  pus. 

Treatment. — These  cases  demand  great  care,  as  they  are 
apt  to  be  made  worse  by  all  exacerbations,  such  as  slight  con- 
gestions initiate.  Every  effort  must  be  made  to  prevent  these 
untoward  occurrences  by  avoiding  chills,  etc.  Dietetic  errors 
are  to  be  guarded  against.  Fluids  should  be  sparingly  taken 
in  the  latter  part  of  the  day.  Tonics  are  sometimes  useful. 
Pulque  appears  to  act  beneficially  upon  catarrhal  affections  of 
the  mucous  membrane  of  the  urinary  tract.  The  occasional 
passing  of  a  soft  catheter  is  often  advantageous.  Opiates 
are  sometimes  absolutely  required;  they  are  best  used  in  the 
form  of  a  suppository.  As  they  are  not  curative,  they  must 
be  employed  judiciously.  It  is  in  this  class  of  case  that  the 
morphine-habit  is  most  likety  to  be  formed.  Belladonna  must 
not  be  used,  as  it  tends  to  impair  still  further  the  expelling 
power  of  the  bladder.  The  subcutaneous  injection  of  ergotin 
has  done  good  service;  but  the  constant  electrical  current 
seems  to  promise  still  better  results. 

Acute  Cystitis. — This  may  arise  from  chills,  from  reten- 
tion of  urine,  from  various  lesions  connected  with  the  nervous 
system,  from  calculus,  from  septic  contamination,  etc.  It  in- 
variably gives  rise  to  much  distress.  The  collection  in  the 
bladder  of  a  few  drops  of  urine  leads  to  exquisite  pain,  and  to 
an  uncontrollable  desire  to  expel  the  accumulated  contents. 


274  Insomnia  and  its  Therapeutics. 

It  is  usually  associated  with  well-marked  constitutional  dis- 
turbance. 

Treatment.—  This  must  be  in  most  cases  decidedly  anti- 
phlogistic, in  which  opiates  and  diluents  hold  a  prominent 
place.  A  suppository  of  morphine  and.  belladonna  at  bedtime 
is  a  useful  means  of  procuring-  sleep.  The  tincture  of  collin- 
sonia  eanadensis,  in  doses  of  3  ss.  to  3  ij-,  appears  to  act  bene- 
ficially. Aconite  and  belladonna  are  also  useful. 

Chronic  Cystitis. — This  depends  upon  the  same  causes  as 
the  acute  variety.  It  may  also  be  caused  by  gonorrhoea, 
stricture  of  the  urethra,  etc.  The  symptoms  resemble  in 
some  degree  those  of  an  enlarged  prostate. 

Treatment. — This  is  very  unsatisfactory  in  many  cases. 
The  medicines  mostly  employed  are  tonics,  buchu,  triticum 
repens,  b^drastis,  uva  ursi,  copaiba,  and  sandal-wood  oil. 
Saccharine  has  been  recommended  of  late. years.  Washing 
the  bladder  once  or  twice  daily  with  weak  solutions  of  quinine, 
resorcin,  boracic  acid,  cocaine,  carbolic  acid,  etc.,  is  the  most 
reliable  remedy.  Opiates  at  night  are  sometimes  unavoid- 
able; they  are  best  given  per  anum.  In  females,  dilatation  of 
the  urethra  is  occasionally  useful. 

Pyelitis. — This  disease  may  result  from  many  causes,  often 
from  inflammatory  mischief  spreading  up  the  ureters,  but  it 
more  commonly  arises  from  calculus  in  the  kidnej'.  It  is  ac- 
companied by  much  more  marked  constitutional  disturbance, 
fever,  loss  of  flesh  and  strength,  progressive  anasmia,  night 
sweats,  etc. 

Treatment. — This  is  even  more  unsatisfactor}1-  than  that  of 
chronic  cystitis.  Tonics,  hydrastis,  eucalpytus,  yellow  santal 
oil,  pulque,  collinsonia  canadensis,  and  opiates,  with  nutritious 
diet,  are  probably  the  best  remedies.  In  this  as  well  as  in  the 
other  similar  diseases  just  considered,  the  exciting  cause  must 
always  be  the  guide  to  the  remedy  selected.  When  calculus 
is  the  cause,  the  nature  of  the  stone  must  be  accurately  ascer- 
tained. 

Irritability  is  invariably  caused  by  vesical  and  renal  calculi, 
which  may  also  induce  secondarily  cystitis  and  pyelitis. 

Vesical  Calculus. — This  always  disturbs  sleep  from  the 
pain  it  causes.  In  children  sleeplessness  and  dreams  are  fre- 
quently the  only  symptoms  of  stone  in  the  bladder.  Irrita- 
bility may  be  absent.  The  treatment  of  vesical  calculus  is 


Insomnia  and  its   Therapeutics,  275 

obviously  surgical.  Palliative  relief  can  be  obtained  only 
from  opium. 

Renal  calculus  very  frequently  gives  intimation  of  its  pres- 
ence during  the  night.  That  appears  to  be  the  favorite  time. 

Treatment. — Morphine  is  urgently  called  for  during  the 
attack  of  pain.  General  treatment  must  be  varied  with  the 
nature  of  the  stone. 

Irritability  of  the  bladder  may  be  set  up  reflexly  by 
hemorrhoids,  fissure  of  anus,  worms,  displacements  of  the 
womb,  and  in  rarer  instances  by  a  floating  kidney.  It  can 
only  be  relieved  by  remedial  measures  directed  to  these  condi- 
tions. 

Sleep  may  be  disturbed  by  attacks  of  chordee,  and  by  a 
distended  bladder,  which  sometimes  causes  restlessness  and 
dreams,  without  incontinence  following.  In  children  this 
source  of  sleeplessness  should  never  be  overlooked.  A  long 
prepuce  requires  surgical  treatment.  In  all  such  cases  the 
child  should  be  wakened  three  or  four  hours  after  going  to 
bed  to  empt}*"  the  bladder. 

Sleep  disturbance  in  children  is  occasionally  due  to  an  ex- 
cessive excretion  of  uric  acid.  In  many,  this  has  no  clinical  sig- 
nificance. Limiting  the  quantity  of  nitrogenous  food,  and  the 
administration  of  alkalies,  are  always  followed  by  improved 
sleep. 

Incontinence  of  Urine. — This  disorder  depends  upon  a 
paroxysmal  neurosis,  and  is  closely  allied  to  sleep-walking. 
It  consists  in  passing  water  during  sleep,  involuntarily  and 
unconsciously. 

Beginning  in  some  instances  in  the  early  years  of  youth,  i'o 
usually  ceases  at  puberty,  although  in  a  few  cases  it  is  con- 
tinued into  adult  life.  In  the  latter  group  it  is  important  to 
discriminate  between  this  variety  of  incontinence  and  that 
which  occurs  in  connection  with  epileptic  seizures  during  sleep. 
It  is  most  commonly  met  with  in  those  who  have  neurotic  ten- 
dencies, and  a  hereditaiy  predisposition  to  it.  Like  chorea, 
epilepsy,  and  other  allied  disorders,  it  may  be  excited  by 
fright,  fear,  or  other  impressions  acting  strongly  upon  the 
emotional  centres;  but  it  may  be  originated  by  reflex  irrita- 
tions, such  as  are  caused  by  a  long  and  tight  prepuce,  increased 
acidity  or  alkalinity  of  the  urine,  constipation,  worms,  or  fis- 
sure of  the  anus.  The  bad  habit  instigated  by  these  exciting 


276  Insomnia  and  its  Therapeutics. 

causes  may  be  perpetuated  for  years;  their  removal  not  being 
immediately  followed  by  immunity  from  it.  The  centres 
which  control  micturition  being  unstable,  they  respond  to  pre- 
ternaturally  slight  impressions;  and  their  stability  requires 
to  be  achieved  ere  the  bad  habit  is  checked. 

The  affection  is  always  troublesome,  and  the  feeling  of 
degradation  it  excites  in  the  minds  of  those  who  suffer  from  it 
is  extremely  annoying.  Ashamed  of  their  infirmity,  they  are 
apt  to  become  shy  and  morose ;  this  is  particularly  the  case 
in  young  women.  Males  and  females  are  equally  liable  to  it. 
Boys  have  been  known  to  manfully  suffer  the  pain  of  the  pre- 
puce sloughing  off,  brought  about  by  themselves  tying  a  cord 
round  it,  in  the  hope  of  controlling  the  disagreeable  symptom. 
It  occasionally  gives  rise  to  serious  consequences.  Nearly 
twenty  years  ago  the  writer  amputated  at  the  upper  third  of 
the  thigh  the  limb  of  a  young  female,  which  had  been  shattered 
in  a  railway  accident.  She  was  a  woman  of  weak  intellect. 
The  following  morning  he  found  the  dressings  saturated  with 
urine,  and  he  was  then  told  that  the  patient  suffered  from  in- 
continence. No  medication  nor  mechanical  device  rendered 
any  effectual  service;  whenever  she  slept  she  spasmodically 
expelled  her  urine.  The  flaps  sloughed,  and  she  died  of  septic 
poisoning. 

It  may  occur  once  or  even  twice  during  the  same  night, 
generally  soon  after  going  to  bed  or  early  in  the  morning; 
often  at  the  same  hour  or  hours,  and  always  when  sleep  is 
deepest.  Trousseau,  who  studied  this  subject  most  carefully, 
pointed  out  that  these  sufferers  are  usually  deep  sleepers,  and 
that  they  may  rise  in  the  early  part  of  the  night  to  empty 
the  bladder,  yet  later  on,  when  sleep  is  most  sound,  they  pass 
water  involuntarily.  It  does  not  depend  upon  the  quantity  of 
water  in  the  bladder,  for  if  the  quantity  were  large  it  would 
awake  the  sleeper;  nor  upon  the  quantity  of  fluid  imbibed:  it 
is  a  neurosis.  Like  other  centres,  those  of  micturition  are 
affected  by  mental  influences.  This  is  demonstrated  by  the 
urgent  desire  to  pass  water  induced  by  fright ;  as  also  by  the 
ability  we  possess  of  inhibiting,  in  our  waking  moments,  the 
calls  to  micturate,  or,  in  other  words,  of  inhibiting  the  centres 
which  dominate  the  detrusor  urinse.  When  we  are  awake 
and  in  good  health  the  detrusor  urinse  and  sphincter  muscles 
are  equally  balanced ;  in  this  affection  the  former  acts  spas- 


Insomnia  and  its   Therapeutics.  277 

medically  during  sleep,  and  expels  the  urine  forcibly.  Where 
the  sphincter  is  weak  it  is  more  easily  overcome,  but  in  these 
cases  there  are  usually  some  signs  of  weakness  displayed  dur- 
ing- the  day. 

The  complaint  may  cease  during1  an  illness  if  sleep  be  in- 
terfered with,  and  reappear  as  health  and  sleep  are  re-estab- 
lished. Although  the  urine  is  passed  unconsciously,  in  many 
instances  the  act  immediately  awakes  the  patient;  it  is  thus 
a  disease  of  sleep  and  a  disturber  of  sleep. 

Treatment. — All  causes  capable  of  setting  up  reflex  irrita- 
tion must  be  removed;  the  bowels  unloaded  and  regulated; 
worms  expelled ;  fissures  cured ;  a  tight  prepuce  stretched  or 
incised,  and  if  adherent,  removed;  a  contracted  meatus  di- 
lated ;  and  abnormal  conditions  of  the  urine  rectified. 

In  the  enfeebled  and  ansemic,  in  whom  the  sphincter  is  apt 
to  be  weak,  general  and  local  faradization  is  sometimes,  if  not 
always,  useful.  The  food  must  be  carefully  selected.  A  cold 
spinal  douche  given  every  day,  lasting  two  or  three  seconds, 
followed  by  gentle  friction  with  a  warm  towel,  with  change  of 
air,  preferably  to  the  country,  are  useful  aids. 

Tonics  combined  with  small  doses  of  cantharides  are  often 
serviceable. 

For  a  child  of  six  years: 

5  Tinct.  canthar.,        .        .        .        .        ,        .    HI  x. 

Vin.  ferri, f  iv. 

M.     Sig.  A  dessertspoonful  thrice  daily  in  water. 

For  a  youth  of  fifteen  years : 

]J   Syr.  phosph.,  ferri,  quin.  et  strychn.,     .        .     f  rj. 

Syr.  phosph.  ferri  co., §  ij. 

Tinct.  canthar., 3  ss. 

M.    Sig.  A  teaspoonful  in  water  after  meals  thrice  daily. 

In  the  cases  in  which  the  general  health  is  obviously  not 
depressed,  careful  attention  must  be  paid  to  the  points  just 
referred  to,  for  everything  should  be  done  to  raise  the  tone  of 
the  nervous  system.  The  hour  at  which  the  water  is  usually 
passed  should  be  noted,  and  if  it  is  possible  sleep  should  be 
interrupted  shortly  before — not  to  pass  water  unless  the  desire 
to  do  so  be  present,  but  to  cause  the  sleep  to  be  less  deep. 
Belladonna  is  the  foremost  remedy  for  this  affection,  and  it 


278  Insomnia  and  its   Therapeutics. 

acts  in  a  remarkable  way  in  reducing  the  irritability  of  the 
centres  of  micturition.  It  also  acts  by  lessening  the  excita- 
bility and  conductivity  of  the  sensory  and  motor  nerves.  This 
is  not  infrequently  seen  in  adults,  who  are  so  susceptible  to  its 
influence  in  some  cases  that  \  or  \  of  a  grain  of  the  extract,  in 
a  laxative  pill,  is  sufficient  to  cause  retention  of  urine.  Chil- 
dren, however,  are  very  tolerant  of  the  drug,  in  most  instances 
bearing  much  larger  doses  than  adults.  It  is  well  to  begin 
with  a  dose  ranging  from  five  to  ten  minims  of  the  tincture 
three  times  a  day,  and  gradually  to  increase  the  dose  until 
its  physiological  effects  are  produced,  for  until  that  point  is 
reached  the  therapeutic  benefits  are  seldom  obtained.  Should 
belladonna  fail,  chloral  hydrate  will  be  found  a  reliable  remedy. 


CHAPTER  XVI. 

INSOMNIA  PECULIAR  TO  FEMALES. 

SLEEPLESSNESS  or  disturbed  sleep  is  apt  to  appear  in  fe- 
males from  causes  peculiar  to  the  sex,  notably  at  the  epochs 
of  puberty  and  the  menopause,  at  the  catamenial  periods, 
during1  pregnancy,  and  after  parturition.  It  chiefly  affects 
those  of  the  neurotic  temperament,  with  highly-strung-  and 
unduly-sensitive  nervous  systems,  and  those  debilitated  by 
neurasthenic  conditions. 

Puberty. — At  this  time  the  body  and  mind  participate  in 
rapid  evolution,  the  physique  is  changed,  and  new  instincts 
and  desires  arise;  the  whole  creature  emerges  into  woman- 
hood. In  the  course  of  transition  the  equilibrium  of  the  nerv- 
ous and  vascular  systems  is  liable  to  be  perturbed.  This  oc- 
casions such  young-  females  to  exhibit  emotional  tendencies,  to 
suffer  from  malaise,  headache,  and  palpitation,  and  sometimes 
to  become  affected  with  chorea  and  epilepsy. 

Disturbed  sleep  at  this  time  is  by  no  means  rare,  and  once 
initiated  it  is  apt  to  recur  at  the  catamenial  periods,  when  evi- 
dence of  increased  nervous  excitability  and  fatigue  is  seldom 
wanting*.  Insomnia  is  a  most  undesirable  symptom  at  such  a 
juncture,  for  a  plentiful  amount  of  sleep  is  urgently  required 
for  the  development  and  recuperation  of  the  nervous  system. 

Treatment. — This  consists  in  adopting  measures  calculated 
to  restore  the  stability  of  the  nervous  sj-stem,  such  as  regu- 
lating the  diet  and  regimen  of  the  patient.  Occasionally,  rest 
in  bed  for  two  or  three  weeks  answers  admirably,  by  recruit- 
ing the  g-eneral  tone  of  the  body.  Galvanization  in  some  in- 
stances suits  excellently.  The  bromides  may  be  given  in  full 
doses  at  bedtime.  It  is  best  to  avoid  morphine  and  other 
powerful  narcotics. 

Menstruation.  —  Insomnia  occurring-  at  the  menstrual 
periods  depends  upon  like  causes,  the  process,  though  a  natu- 
ral one,  perturbing-  the  sj^stem.  The  perturbation  is  a  gen- 


280  Insomnia  and  its   Tlierapeutics. 

eral,  as  well  as  a  local,  one.  The  body-temperature  is  modified, 
and  the  nervous  and  circulatory  systems  are  disturbed.  The 
implication  of  the  nervous  system  is  readily  recognized; 
sudden  mental  emotion  can  arrest  the  flow.  On  the  other 
hand,  the  recurring  periods  give  rise,  in  many,  to  sick-headache, 
variations  in  temper,  and  restlessness  during  the  day,  and  to 
dreams  and  sleep  disturbance  at  night.  Its  effects  can  also 
be  well  studied  in  this  class  of  patients,  when  they  are  also 
the  subjects  of  slight  visual  defects.  They  complain  of  errors 
of  refraction  at  these  recurring  times,  being  powerless  to  over- 
come them  by  accommodation  as  they  are  able  to  do  in  the 
intervals.  They  can  be  equally  well  observed  in  a  large  num- 
ber of  females  whose  digestive  powers  are  limited — whose 
organs  are  able  to  cope  with  the  daily  work  in  the  intervals, 
but  which  are  quite  inadequate  at  these  periods.  The  excre- 
tions also  are  all  more  or  less  interfered  with.  Hence  it  is 
that  dyspeptic  troubles  arise  at  these  times,  and  so  frequently 
become  a  source  of  sleep  disturbance.  The  derangement  of 
the'  equilibrium  of  the  vascular  system  leads,  occasionally,  to 
alterations  in  the  quantity  of  blood  in  the  thyroid  gland.  As 
that  gland  exercises  an  important  influence,  both  over  the 
cerebral  circulation  and  on  sleep,  modification  of  its  functions 
may  account,  to  some  extent,  for  the  sleep  troubles.  It  is  un- 
doubted that  sleep  derangement  is  more  common  in  young 
women  than  in  young  men.  They  are  more  susceptible  to  the 
influence  of  toxic  agents,  notably  of  lead.  This  can  only  be 
explained  by  the  vulnerability  of  their  constitutions  which  the 
menstrual  functions  inaugurate.  It  is  more  marked  in  some 
families  than  in  others,  just  as  some  families  have  a  greater 
proclivity  to  sleeplessness. 

Treatment, — This  must  be  conducted  upon  the  foregoing 
principles,  but  the  following  pill  may  be  given  for  a  few  nights. 

IJ.  Ext.  stramon.,     ......  gr.  £. 

Pulv.  camphor.,  .        «        .        ...  gr.  ij. 

Ext.  hyoscy., gr.  iij. 

Ft.  pil.  i.     Sig.  Take  one  at  bedtime. 

Tonics  sometimes  do  good. 

Dysmenorrhcea,  menorrhagia,  and  over-lactation  cause 
insomnia.  It  is  usually  due,  in  the  latter  cases,  to  cerebral 
anaemia.  The  symptoms  which  these  patients  complain  of  are 


Insomnia  and  its   Therapeutics.  281 

all  indicative  of  mal-nutrition  of  the  nervous  centres;  their 
sight  is  dim,  and  it  is  greatly  affected  by  all  sudden  altera- 
tions of  posture.  Hearing1  is  dulled,  and  noises  in  the  ears  are 
seldom  absent,  while  the  general  sense  of  touch  is  usually  im- 
paired. The  general  symptoms  are  those  of  anaemia. 

Treatment. — Such  cases  of  insomnia  require  that  the  bodily 
drain  be  checked,  and  that  the  tone  of  the  nervous  and  vascu- 
lar systems  be  invigorated  by  suitable  remedies,  such  as  were 
indicated  in  discussing  the  subject  of  cerebral  anaemia. 

Displacements  of  the  womb,  with  which  frequent  micturi- 
tion is  often  associated,  and  some  diseases  of  the  ovaries,  give 
rise  reflexly  to  insomnia,  a  symptom  which  can  only  be  re- 
lieved by  the  rectification  and  alleviation  of  the  disturbing 
causes. 

Amenorrhcea  with  chlorosis  has  insomnia  as  a  symptom. 
A  few  words  must  be  said  regarding  it.  It  depends  upon  the 
depravity  of  the  blood  peculiar  to  the  latter,  which  not  only 
interferes  with  the  nutrition  of  the  nervous  system,  but  brings 
about  modifications  of  vascular  tension,  and  invariably  leads 
to  defective  digestion,  often  characterized  by  painful  symp- 
toms, as  gastralgia.  These  combine  to  disturb  sleep.  The 
late  Dr.  Graves  pointed  out  a  very  curious  fact  concerning 
this  form  of  insomnia.  He  wrote :  "  It  is  singular  how  long 
sleeplessness  often  continues  in  chlorosis  without  inducing 
those  serious  consequences  that  are  produced  by  this  symp- 
tom in  other  morbid  states  of  the  system."  The  writer  has 
no  explanation  to  offer  of  this  fact;  he  can  only  confirm  the 
accuracy  of  the  observation.  His  friend,  Dr.  Mackintosh,  has 
suggested  that  it  may  be  due  to  the  small  amount  of  tear  and 
wear  of  the  tissues  in  chlorosis,  requiring  less  recuperative 
action. 

Treatment. — This  consists  in  remedying  the  state  of  the 
blood  and  re-establishing  the  menstrual  flow,  which  is  best 
accomplished  by  means  of  warm  laxatives  and  ferruginous 
tonics.  The  old  combination  of  Griffith's  mixture  and  the 
compound  decoction  of  aloes,  is  an  admirable  one.  Blaud's 
pills,  in  doses  of  from  one  to  four,  taken  after  meals  thrice 
daily,  with  an  efficient  dose  of  infusion  of  senna  pods  at  bed- 
time, also  answers  well.  Arsenic  is  occasionally  valuable. 
This  medication  may  be  varied  at  the  recurring  periods  by 
the  administration  of  the  precipitated  oxide  of  manganese,  or 


282  Insomnia  and  its  Therapeutics. 

the  permanganate  of  potassium,  to  promote  the  menstrual 
flow. 

Menopause. — At  the  menopause,  as  at  puberty,  sleep  is  apt 
to  be  disturbed.  Cases  of  unusually  prolonged  sleep  occurring 
in  this  connection  have  frequently  been  recorded,  but  the 
more  common  disturbance  is  that  of  want  of  sleep.  It  will  be 
seen  from  the  tables  (page  550)  that  the  menopause  caused  18 
out  of  273  consecutive  cases  of  insomnia.  The  changes  at  this 
important  epoch  are  vast  and  momentous;  the  whole  repro- 
ductive apparatus  is  functionally  metamorphosed  from  a  state 
of  nervous  and  vascular  activity  into  one  of  repose.  As  this 
does  not  take  place  in  the  various  parts  involved  in  the  gen- 
erative functions  simultaneously,  disorders  are  apt  to  super- 
vene. For  instance,  the  ovaries  during  this  important  period 
are  preternaturally  irritable  and  excitable.  In  the  course  of 
the  months  or  years  that  this  decadence  is  progressing,  be- 
sides a  liability  to  floodings,  which  are  productive  equally  of 
anaemia  and  sleeplessness,  a  train  of  nervous  symptoms  are 
apt  to  ensue,  such  as  occipital  headache,  giddiness,  depression 
of  spirits,  hypochondriasis,  hysteria,  irritability  of  temper, 
flushings,  chills,  perspirations,  etc.  The  perspirations  fre- 
quently come  on  at  4  or  5  A.M.  and  cause  awaking,  and  they 
are  often  associated  with  palpitation.  In  some  cases  there  is 
perversion  of  the  moral  sense,  and  even  insanity.  Lithiasis 
very  often  manifests  itself  at  this  time,  and  gives  rise  to  in- 
creased arterial  tension  and  palpitation  of  the  heart. 

•  Dr.  Saundby,  of  Birmingham,  and  others,  have  described  a 
form  of  tingling  and  numbness  ("  pins  and  needles  ")  which  is 
apt  to  come  on  in  the  limbs  during  sleep  and  to  interrupt  it. 
Dr.  Ormerod  thought  it  most  common  at  the  menopause. 
The  writer  has  met  with  several  cases  at  that  epoch,  in  which 
the  upper  and  lower  limbs  were  variously  affected.  Its  onset 
certainly  terminates  sleep.  In  most  of  the  cases  it  appeared 
to  depend  on  the  gouty  taint ;  it  quickly  disappeared  on  anti- 
gouty  treatment. 

Sleeplessness  and  sleep  disturbed  by  dreams  are  usually 
the  most  constant  symptoms  of  all.  Probably  unmarried 
women  suffer  more  from  these  disagreeable  symptoms  than 
their  married  sisters. 

These  cases  are  mainly  divisible  into  two  classes,  the  ple- 
thoric and  anaemic. 


Insomnia  and  its   Therapeutics.  283 

Treatment. — The  plethoric,  in'  whom  blood-pressure  is 
markedly  increased,  and  those  in  whom  headache  is  a  promi- 
nent symptom,  may  be  relieved  by  bleedings  from  the  temples, 
repeated  at  the  periods  when  the  catamenial  flow  shall  have 
appeared,  and  also  by  mercurials  and  alkalies. 

1J  Subchlor.  hydrarg., gr.  L 

Ext.  hyoscy., gr.  iij. 

Ft.  pil.  i.    Sig.  Take  one  every  tenth  night. 

5  Tinct.  aconit.  (B.  P.),  .        .       '.        .        .Til  xxiv. 
lodid.  potass.,       ,        .        .        .        .        .3L 

Bicarb,  potass., 3  iij. 

Aq.  menth.  pip., ad  §  vi. 

M.  Sig.  Take  a  tablespoonful  in  water  before  meals  thrice 
daily. 

The  nitrites  are  efficient  remedies. 

Turkish  baths  carefully  managed  are  useful  adjuncts  to 
treatment.  The  inhalation  of  amyl  nitrite  (TTJ,  iij.)  at  bedtime, 
or  during  the  night  if  sleep  be  interrupted,  occasionally  acts 
as  a  hypnotic.  This  can  be  convenientl}*  prescribed  in  cap- 
sules. The  bromides  may  be  given  for  limited  periods,  as 
during  the  week  when  the  loss  should  naturally  recur.  The 
dose  most  suitable  is  3  ss.  at  6  and  again  at  10  P.M.  A  resi- 
dence at  Kissingen  or  Bath  is  beneficial. 

In  the  anaemic  cases  arsenic  and  iron  are  the  remedies 
called  for.  The  syrup  of  bromide  of  iron,  or  of  bromide  of  iron 
with  quinine  and  strychnine,  in  3  i.  doses  thrice  daily  after 
meals,  answers  well.  These  should  be  taken  through  a  tube, 
as  they  are  apt  to  discolor  the  teeth.  The  feeding  should  be 
generous,  but  stimulants  must  be  prescribed  cautiously,  if  at 
all.  Some  of  these  patients  improve  at  Schwalbach  and  Hom- 
burg,  others  in  Switzerland.  The  bromides  must  not  be  given 
for  any  length  of  time,  as  they  increase  the  anaemia.  Chloral 
hydrate  and  morphine,  like  alcohol,  are  dangerous  remedies 
on  account  of  the  especial  tendency  at  this  epoch  to  the 
formation  of  injurious  habits.  In  a  case  recently  under  treat- 
ment sulphonal  failed  to  induce  sleep  satisfactorily,  although 
it  was  pushed  to  the  extent  of  causing  very  pronounced 
drowsiness,  and  some  inco-ordination  of  movement  in  the  day- 
time. Belladonna  with  cannabis  indica  and  camphor  eventu- 


284  Insomnia  and  its   Therapeutics. 

ally  produced  sleep.  Paraldehyde  and  urethane  are  generally 
reliable  and  suitable  drugs. 

Pregnancy. — Although  pregnancy  is  a  natural  process,  it 
inaugurates  conditions  so  novel  as  in  many  cases  to  disturb 
the  equilibrium  of  the  nervous  and  vascular  systems.  This  is 
evidenced  by  a  train  of  symptoms  chiefly  referrible  to  these 
systems,  and  mainly  seen  in  women  who  are  neurotic,  deli- 
cate, and  sensitive,  and  pregnant  for  the  first  time,  although 
the  multiparous  are  not  exempt.  These  symptoms  differ 
widely  in  character,  and  are  the  source  of  much  discomfort 
and  suffering.  Such  patients  become  emotional  and  mentally 
perturbed,  depressed  and  introspective,  brooding  over  trifles, 
and  having  a  groundless  dread  of  impending  evil.  They  suffer 
from  neuralgic  pains  and  cramps,  from  morning  sickness, 
acidity,  flatulence,  and  constipation;  also  from  palpitation, 
and,  as  Dr.  Broadbent  pointed  out,  from  increased  vascular 
tension,  which  may  be  due  to  the  cardiac  hypertrophy  invari- 
ably present,  and  perhaps  in  a  less  degree  to  the  rapid  tissue- 
change  going  on  in  the  body.  The  combined  vascular  modi- 
fications are  so  considerable  as  to  lead,  in  the  majority  of 
pregnant  women,  to  the  production  of  functional  cardiac  mur- 
murs. These  symptoms,  united  with  others  of  less  import, 
"bring  about  hyperaemia  of  the  brain  and  consequent  cerebral 
activity,  which  is  attended  by  sleeplessness.  Cramps  in  the 
limbs  not  infrequently  interfere  with  sleep.  They  are  proba- 
bly due  to  the  rapid  metamorphosis  just  referred  to;  some- 
times they  are  caused  by  pressure  on  nerves. 

Treatment. — This  must  be  conducted  upon  general  prin- 
ciples, the  object  being  to  build  up  the  nervous  system,  to 
engender  confidence  and  hope,  and  to  calm  the  vascular  sys- 
tem. The  patient  must  be  counselled  to  lead  a  regular  life, 
to  be  much  in  the  open  air  without  fatigue,  to  observe  early 
hours,  and  to  have  pleasant  and  peaceful  society.  All  diges- 
tive derangements  and  disorders,  such  as  pruritus,  must  be 
rectified.  The  bromides  are  useful,  particularly  bromide  of 
lithium,  either  alone  or  in  combination. 

$  Brom.  lithii, gr.  xv. 

Tinct.  lupul., 3  ss. 

Aq.  chlorof.,        .        .        .        .  ad  f  i. 

M.  ft.  haust.     Sig.  Take  at  bedtime. 


Insomnia  and  its   Therapeutics.  285 

The  monobromide  of  camphor  in  4-grain  doses  is  often 
helpful. 

Parturition. — It  occasionally  happens  that  a  hypersensi- 
tive woman,  during-  a  prolonged  or  severe  labor,  suffers  so 
much  from  shock  to  the  nervous  system  that  she  becomes  irri- 
table, restless,  intolerant  of  all  disturbing-  influences,  and  sleep- 
less. The  pulse,  instead  of  falling  in  the  usual  marked  way, 
continues  to  beat  quickly,  and  that  without  any  accompany- 
ing rise  of  temperature,  indicating  that  the  innervation  of  the 
heart  is  perturbed.  The  insomnia  may  be  complete,  and  it  may 
persist  during  several  nights.  It  is  always  a  symptom  of 
grave  import,  for  if  unrelieved  it  may  usher  in  puerperal  in- 
sanity. It  is,  indeed,  the  most  pronounced  premonitory  symp- 
tom of  that  malady.  When  the  want  of  sleep  lasts  some 
days,  fever  and  'other  constitutional  symptoms  appear,  which 
intensify  the  distress.  In  another  class  of  cases  the  patient 
does  not  sleep  throughout  the  first  night,  but  may  feel  unusu- 
ally well,  and  gradually  symptoms  of  disturbance  ensue, 
which  terminate  in  some  toxicohaemic  disorder.  This  loss  of 
sleep,  with  a  feeling  of  exaltation,  not  rarely  prognosticates  ill. 
Euphoria  after  parturition,  and  after  operations,  invariably 
portends  mischief.  Without  an}"  other  symptom  to  justify  it, 
it  inspires  the  physician  with  dread.  He  knows  its  meaning 
only  too  well.  The  patient's  manner  is  changed,  she  becomes 
unnaturally  effusive,  and  apparently  delights  to  reiterate  the 
statement  that  she  is  so  well  she  is  quite  able  to  get  up.  The 
writer  has  been  accustomed  to  base  his  prognosis  on  sleep. 
If  the  patient  has  slept  well  and  soundly  she  may  go  on  nicely. 
4  If  she  has  not  she  seldom  escapes  an  illness. 

Sleeplessness  may  depend  upon  more  marked  causes.  For 
example,  it  frequently  follows  post-partum  hemorrhage,  and 
is  then  due  to  acute  anaemia  of  the  brain;  it  is  also  maintained 
by  severe  after-pains,  pains  which  in  moderation  subserve  a 
useful  physiological  purpose,  but  in  excess  lead  to  constitu- 
tional disturbance,  which  the  loss  of  sleep  greatly  aggravates. 

In  no  condition  are  the  benign  influence  of  sleep  and  the  dis- 
astrous effects  of  insomnia  so  well  exemplified. 

Treatment. — That  sleep  may  not  be  thwarted  it  is  of  the 
utmost  importance  that  there  should  be  a  complete  absence  of 
sounds  in  the  bedroom,  which  should  be  darkened  and  well 
ventilated.  Hypnotics  are  of  the  greatest  value,  and  they 


286  Insomnia  and  its  Therapeutics. 

must  be  pushed  until  sound  sleep  is  induced.     The  monobro- 
mide  of  camphor,  in  4-grain  doses,  is  reliable ;  also  the  following-  : 

5,  Liq.   morph.  acet., 3ij. 

Spt.  chlorof., ,        .    3  ij. 

Tinct.  digital., 3ij. 

Mist,  camphor.,        .        .        .        .        .      ad  §  iv. 
M.    Sig.  Take  one-fourth  every  hour  until  sleep  is  induced. 

Morphine  with  atropine  may  be  given  subcutaneously.  A 
small  allowance  of  alcohol  often  acts  beneficially. 

After  post-partum  hemorrhage  the  remedy  is  the  hypo- 
dermic injection  of  morphine,  with  small  quantities  of  alcohol. 
During  convalescence  sleep  is  materially  improved  by  the  use 
of  salines  and  digitalis. 

For  after-pains  sedatives  are  required,  but  when  they  are 
neuralgic  in  character  no  remedy  relieves  them  so  speedily  as 
acupuncture,  with  a  fine  needle,  over  the  lower  part  of  the 
sacrum  and  coccyx,  as  recommended  by  the  late  Dr.  Sidey  of 
Edinburgh. 

For  some  months  after  a  severe  confinement  the  patient 
may  continue  somewhat  sleepless  and  even  hypochondriacal. 
This  condition  is  best  relieved  by  the  treatment  indicated  as 
useful  for  hypochondriasis.  It  must,  however,  be  mentioned 
that  tincture  of  cimicifuga,  a  remedy  highly  praised,  in  other 
cases,  by  the  late  Sir  J.  Y.  Simpson,  sometimes  affords  excel- 
lent results. 


CHAPTER  XVII. 

BATHS.— ELECTRICITY. 

THE  writer  appends  a  very  brief  summary  of  some  remedial 
measures  he  has  found  useful  in  the  treatment  of  insomnia. 
These  embrace  the  cold  bath,  sitz  bath,  spinal  douche,  spray 
or  needle  bath,  cold  foot  bath,  salt  bath,  wet  pack,  hot  foot 
bath,  hot  bath,  Turkish  bath,  and  lamp  bath;  and  also  elec- 
tricity. 

BATHS. 

Baths  are  so  serviceable  in  the  treatment  of  insomnia  that 
a  short  reference  must  be  made  to  their  physiological  effects. 

The  Cold  Bath. — The  morning1  plunge  in  cold  water  is  an 
important,  if  usual,  process,  being  an  excellent  tonic  and  de- 
rivative. The  first  effect  of  the  bath  is  to  cause  contraction 
of  the  muscular  fibres  of  the  skin,  producing  the  appearance 
called  goose-skin,  a  process  which  has  been  styled  cutaneous 
gymnastics.  Coincidently,  the  blood-vessels  of  the  periphery 
contract,  while  those  of  the  brain  dilate.  The  cardiac  con- 
tractions and  respirations  are  quickened,  and  the  blood-pres- 
sure is  raised.  This  is  immediately  followed  by  a  concurrent 
dilatation  of  the  peripheral  and  a  contraction  of  the  cerebral 
blood-vessels,  slowing  of  the  heart  and  respirations,  and  low- 
ering of  the  blood-pressure.  The  reaction,  as  it  is  called,  is 
much  aided  by  cutaneous  friction.  When  reaction  is  good  it 
is  accompanied  by  a  feeling  of  lightness  and  elasticity  of  the 
body,  and  by  a  desire  for  active  mental  and  physical  exertion. 

The  Sitz  Bath. — As  regards  the  action  of  the  sitz  bath  it 
is  found  that  the  cold  water  causes  contraction  of  the  blood- 
vessels of  the  cutaneous  surface  and  of  the  superficial  muscles, 
and  reflexly  those  of  the  pelvis  and  abdomen,  the  cardiac  con- 
tractions at  the  same  time  becoming  less  frequent,  and  the 
blood-pressure  being  raised.  After  the  bath  reaction  sets  in, 
and  the  blood-vessels  dilate,  attracting  and  retaining  for  a 


288  Insomnia  and  its  Therapeutics. 

time  a  large  volume  of  blood,  so  that  the  cerebral  vessels  are 
partially  depleted;  and  this,  together  with  the  marked  tonic 
effect  produced  by  the  bath  on  the  nervous  system,  renders 
intelligible  the  favorable  results  so  often  accruing  in  the  treat- 
ment of  insomnia  by  the  sitz  bath. 

When  a  more  pronounced  effect  is  desired  it  can  be  accom- 
plished in  one  of  two  ways:  by  a  particular  construction 
known  as  the  "  running  sitz,"  in  which  an  inlet  and  exit  pipe, 
each  of  equal  calibre,  allow  of  a  constant  supply  of  cold  water, 
and  by  having  two  sitz  baths  placed  side  by  side,  the  one  con- 
taining- cold  and  the  other  hot  water,  so  that  the  bather  can 
move  quickly  from  one  to  the  other.  This  is  probably  one  of 
the  most  efficacious  derivatives  we  possess. 

The  sitz  bath  should  be  raised  from  the  floor  to  such  a 
height  as  will  allow  the  bather  to  sit  in  it  comfortably,  and 
should  contain  from  four  to  five  inches  of  cold  water,  this 
being  usually  sufficient  to  cover  the  hips  and  lower  part  of 
the  abdomen.  During1  the  process  the  body  should  be  covered 
with  a  warm  wrap,  and  the  duration  of  the  bath  varied  ac- 
cording to  the  strength  of  the  bather  and  the  effect  desired, 
from  five  to  thirty  minutes  being  the  usual  limits.  After  the 
bath  has  been  completed  the  skin  should  be  dried  with  a  warm 
towel,  and  then  rubbed  briskly  with  a  flesh  brush. 

The  Spinal  Douche. — This  is  a  column  of  cold  water  fall- 
ing from  a  height  with  some  force  upon  the  back  of  the  neck 
and  down  the  spine.  It  is  a  most  powerful  stimulant  to  the 
medulla  oblongata  and  the  centres  it  contains,  and  is  best 
taken  standing  with  the  feet  in  hot  water.  If,  however,  no 
special  arrangement  exists  in  the  bath  room,  it  can  be  im- 
provised with  a  large  can  of  water  poured  from  a  height  while 
the  patient  sits  in  a  sitz  bath.  In  enfeebled  states  this  power- 
ful remedy  must  be  cautiously  used.  The  alternate  spinal 
douche  of  hot  and  cold  water  is  less  severe,  and  is  almost 
equally  efficacious. 

Spray  or  Needle  Baths. — These  are  highly  stimulating  to 
the  nervous  system,  imparting  a  sharp  shock  to  it,  which  is 
speedily  followed  by  reaction.  They  should  be  of  short  dura- 
tion, the  time  being  proportioned  to  the  strength  of  the  pa- 
tient, who  ought  to  stand,  during  the  process,  with  his  feet  in 
hot  water.  When  reaction  is  slow  they  may  be  used  hot  and 
cold  alternately,  or  warm  throughout,  a  cold  wave  being 


Insomnia  and  its   Therapeutics.  289 

allowed  to  flow  upon  the  upper  part  of  the  spine  for  a  few 
seconds  to  "  finish." 

The  Cold  Foot  Bath  is  in  certain  cases  an  energetic  de- 
rivative. The  feet  and  ankles  are  placed  in  cold  water  for 
five  or  more  minutes,  then  rubbed  with  a  warm  towel,  warm 
stocking's  put  on,  and  a  short  walk  taken  to  induce  a  some- 
what lasting  hypersemia  of  the  feet. 

The  Salt  Bath. — Sea-bathing  is  particularly  invigorating, 
especially  when  the  patient  can  swim.  Within  strict  limits 
(the  duration  not  to  exceed  the  onset  of  reaction)  the  salt  bath 
is  one  of  the  most  powerful  tonics  we  possess,  acting  upon  the 
nervous  and  circulatory  systems  so  as  to  raise  the  tone  of  the 
whole  body.  This  is  evidenced  by  a  feeling  of  well-being  and 
an  inclination  for  exertion,  by  the  appetite  increasing,  and  di- 
gestion and  assimilation  becoming  more  speedy  and  complete. 
The  motion  of  the  waves  against  the  body  considerably  aug- 
ments the  tonic  effects  of  the  salt  bath. 

"Whatever  cold  bath  be  selected,  it  is  best  taken  an  hour 
before  meals,  and  it  should  always  be  followed  by  brisk  flesh- 
brushing  and  a  short  walk. 

All  cold  baths  are  unsuitable  at  the  menstrual  periods. 

The  Wet  Pack. — This  is  a  derivative  and  calmative  of  the 
highest  order,  and  is  very  advantageously  used,  in  pronounced 
cases,  in  connection  with  either  the  cold  sitz  or  the  Turkish 
bath.  Ringer,  in  his  work  on  Therapeutics,  quotes  the  follow- 
ing directions  for  managing  the  wet  pack  from  Dr.  Johnson's 
writings  on  Hydropathy,  which  are  so  good  that  they  are 
here  reproduced.  "Upon  the  mattress,  and  extending  over 
the  pillow,  two  blankets  are  spread,  and  over  this  a  sheet 
wrung  out  as  dry  as  possible  with  cold  water.  The  patient 
lies  down  on  his  back,  perfectly  unclothed,  with  his  head  com- 
fortably placed  on  the  pillow ;  an  attendant  now  approaches, 
say  on  the  patient's  left,  and  first  puckering  the  blanket  from 
the  back  of  the  head  down  to  the  back  of  the  neck,  reaches 
across  his  chest,  seizes  the  right  upper  corners  of  the  blanket, 
and  brings  them  tightly  across  under  the  chin  to  his  own  side 
(the  left),  and  tucks  them  well  and  evenly  under  the  left  shoul- 
der, where  it  joins  the  root  of  the  neck,  and  under  the  point  of 
the  same  shoulder.  He  now  reaches  across  the  body  again, 
and  brings  over  all  the  rest  of  the  right  sides  of  the  blankets 
to  the  left  side  of  the  patient,  and  then  proceeds  to  tuck  them 


290  Insomnia  and  its   Therapeutics. 

well  and  evenly  under  the  left  side,  beginning"  where  he  left 
off,  at  the  point  of  the  shoulder,  and  proceeding  quite  down  to 
the  heels.  The  patient  is  now  entirely  enveloped  in  one  half 
of  the  blankets  and  the  attendant  finishes  the  operation  by 
passing  over  to  the  right  side  of  the  patient,  and  then  pro- 
ceeding to  tuck  the  left  sides  of  the  blanket  under  the  right 
side  precisely  in  the  same  manner  as  we  have  seen  him  tuck 
the  right  sides-  of  the  blanket  under  the  left  side  of  the  pa- 
tient. The  attendant,  standing  on  the  right  side  of  the  pa- 
tient's legs,  finally  insinuates  his  left  hand  under  the  backs  of 
the  ankles,  lifts  them  up,  and  then  with  his  right  hand  turns 
back  the  lower  ends  of  the  blanket  under  the  heels.  .  .  .  The 
wet  sheet  should  reach  to  the  ankles,  and  ...  be  wide  enough 
to  overlap  in  front  of  the  body  about  eight  or  twelve  inches; 
over  the  whole  four  or  five  blankets  are  placed,  and  pressed 
down  close  to  the  sides." 

It  is  a  great  improvement  to  put  a  hot  water  bag  to  the 
feet  before  folding  them  up  in  the  manner  specified,  and  also 
to  apply  a  cold  water  cloth  to  the  forehead.  The  patient  may 
drink  cold  water  if  he  desires,  and  should  remain  in  the  pack 
for  an  hour,  during  which  time  he  will  probably  fall  asleep. 
At  the  end  of  the  process  he  should  sponge  himself  rapidly 
dowrn  with  tepid  water,  and  get  into  bed.  Some  patients  ob- 
ject to  this  remedy  on  account  of  the  trouble  it  involves,  but 
if  the  details  are  methodically  arranged  beforehand  the  whole 
application  is  easily  and  speedily  managed. 

Hot  Foot  Bath. — This  has  long  been  recognized  as  a  do- 
mestic hypnotic.  It  acts  as  a  derivative  to  the  brain  by 
dilating  the  blood-vessels  of  the  feet  and  limbs.  This  vascular 
relaxation  may  persist  for  several  hours,  during  which  time 
there  is  a  corresponding  anaemia  of  the  brain. 

The  Hot  Bath  acts  in  a  similar  manner,  though  much 
more  powerfully.  It  first  increases  the  force  and  frequency 
of  the  action  of  the  heart,  and  produces  hyperasmia  of  the 
brain;  but  these  conditions  are  speedily  reversed,  the  heart 
beating  with  diminished  strength,  the  blood-vessels  of  the 
body  generally  dilating,  while  the  cerebral  vessels  become 
concurrently  anaemic.  If  it  is  unduly  prolonged  these  condi- 
tions tend  to  induce  a  sense  of  oppression  and  faintness.  The 
utility  of  a  hot  bath  at  bedtime  in  promoting  sleep  is  some- 
what uncertain,  suiting  many  patients  admirably,  but  in 


Insomnia  and  its   TJierapeutics.  291 

others  causing  a  degree  of  excitement  which  is  fatal  to 
sleep. 

The  Turkish  Bath,  taken  under  medical  advice,  is  an  effi- 
cacious means  of  restoring  sleep  in  Certain  forms  of  insomnia. 
This  bath  is  derivative  in  all  its  stages — the  copious  perspira- 
tion causing  rapid  elimination  through  the  skin,  the  sham- 
pooing and  kneading  exciting  a  quicker  flow  of  blood  and 
lymph  through  the  whole  body,  while  the  subsequent  cold  or 
cool  douching  induces  rapid  oxidation. 

It  has,  further,  a  derivative  action,  flushing  the  skin  and 
superficial  muscles  with  a  large  volume  of  blood,  while  the 
surcharged  cerebral  vessels  are  relieved  to  a  corrseponding 
extent.  As  regards  vascular  tension,  the  commonly  received 
opinion,  with  which  the  writer  agrees,  is  that  during  the  time 
spent  by  the  bather  in  the  hot  chamber  it  is  lowered ;  although 
it  must  be  mentioned  that  Dr.  W.  J.  Fleming,  of  Glasgow,  in 
some  interesting  observations  made  upon  himself,  and  recorded 
in  the  thirteenth  volume  of  the  "Journal  of  Anatomy  and 
Physiology,"  states  that  "the  principal  effect  upon  the  arterial 
tension  seems  to  be  an  increase  produced  bjT  the  greater  rapid- 
ity of  the  heart's  action  combined  with  the  dilated,  wre  might 
almost  say  gorged,  condition  of  the  capillarj'  circulation." 

The  Turkish  bath  exactty  suits  the  requirements  of  many 
cases  of  insomnia,  relieving  the  cerebral  congestion,  acting  as 
a  tonic  to  the  nervous  and  circulatory  systems,  aiding  diges- 
tion, and  increasing  assimilation.  Well  and  judiciously  used, 
it  is  a  great  boon  to  the  sedentary  and  wakeful  brain-worker, 
and  the  cases  in  which  it  is  contra-indicated  are  extremely 
rare.  The  full  benefit,  as  a  rule,  is  not  derived  until  after  six 
or  seven  baths  have  been  taken;  in  fact,  discomfort  may  be 
increased  and  wakefulness  intensified  after  the  first  or  second, 
especially  if  perspiration  is  not  easy  and  free.  Subsequently, 
a  buoyant  feeling  of  well-being  is  experienced,  and  the  weight 
of  the  bod}"  shows  a  tendency  to  increase,  the  latter  being  a 
point  of  some  importance.  Decrease  in  body-weight,  after  a 
course  of  six  or  eight  baths,  ought  to  lead  to  the  question  of 
the  advisability  of  their  employment  being  reconsidered.  It 
is  important  that  these  baths  should  not  be  resorted  to  with- 
out advice  as  to  the  extent  to  which  they  should  be  carried, 
and  the  frequency  with  which  they  ought  to  be  taken.  For 
it  must  not  be  forgotten  that  the  effects  of  a  prolonged  stay 


292  Insomnia  and  its   TJierapeutics. 

in  an  extremely  hot  rcom  (200°  Fahr.)  are  very  marked.  The 
pulse  is  much  quickened,  possibly  to  120,  the  temperature  is 
raised  to  103°  Fahr.,  and  the  number  of  respirations  to  twenty 
per  minute.  An  equally  useful  bath  may  be  obtained  by 
spending1  the  time  in  a  much  lower  temperature,  in  which  the 
respiration,  temperature,  and  pulse  rate  are  unaffected.  It 
is  likewise  of  some  consequence  that  the  bath  be  thoroughly 
ventilated  and  the  air  quite  dry. 

A  few  general  directions  as  to  the  use  of  the  Turkish  bath 
may  not  be  out  of  place.  In  London  most  of  the  public  baths 
have  four  hot  rooms,  the  temperature  ranging  from  110°  to 
240°  Fahr.  That  in  the  first  room  averages  110°,  in  the 
second  140°,  in  the  third  175°,  and  in  the  fourth  230°  to  240°. 
Upon  entering  the  first  room  the  bather  should  have  his  head 
douched  with  tepid  or  cold  water,  so  that  it  may  be  the  first 
part  of  the  bocty  to  perspire,  thus  lessening  any  tendency  to 
increase  the  cerebral  congestion.  During  the  course  of  the 
bath,  throbbing  of  the  blood-vessels  of  the  head  may  be  allayed 
by  the  application  of  a  cold  wet  turban;  and  palpitation  of 
the  heart,  or  oppression  of  breathing,  may  likewise  be  relieved 
by  placing  a  cold  wet  towel  over  the  chest,  while,  at  the  same 
time,  cold  water  is  freely  sipped.  After  a  short  time  the 
bather  should  proceed  into  the  second  room,  and  again,  after 
a  few  minutes,  into  the  third,  and  there  recline  until  perspira- 
tion is  freely  established,  when  he  should  retrace  his  steps  in 
reverse  order,  and  pass  the  bulk  of  the  hour  or  half  hour  he 
spends  in  the  hot  chamber  in  the  first  room.  It  is  a  mistake 
for  the  beginner  to  enter  the  fourth  or  hottest  room  at  all 
until  he  is  "  seasoned,"  though  old  bathers  prefer,  and  rightly, 
to  proceed  at  once  into  either  the  third  or  fourth  room,  and 
remain  until  perspiration  has  commenced,  returning  to  the 
first  room  to  spend  there  the  rest  of  the  time.  Should  there 
be  any  difficulty  or  delay  in  starting  the  perspiration,  the 
bather  had  better  request  the  attendant  to  spray  him  with 
warm  or  hot  water  in  the  spray  room,  and  it  will  be  found  on 
returning  to  the  hot  room  that  the  skin  begins  to  act  freely. 
After  being  shampooed,  soaped,  and  washed  down,  it  is  de- 
sirable to  "  finish  "  with  a  tepid,  cool,  or  cold  spray,  or  with  a 
short  swim  through  the  moderately  cold  plunge  bath,  accord- 
ing as  it  is  deemed  best  for  the  health  of  the  bather,  and  as 
the  temperature  of  the  weather  permits.  He  should  then 


Insomnia,  and  its   Therapeutics.  293 

proceed  to  the  dressing  apartment,  and  recline  for  at  least 
half  an  hour,  with  the  feet  warmly  wrapped  up  in  a  thick 
towel.  In  dressing,  the  hair  ought  to  be  thoroughly  dried. 
During  the  sweating  process  in  the  hot  room  it  is  common  to 
see  bathers  drowsy,  and  making  efforts  to  resist  sleep;  and 
still  more  common  is  it  to  see  a  number  of  bathers  sound 
asleep  in  the  dressing  room  after  the  completion  of  the  bath. 
Attendants  engaged  daily  in  the  occupation  of  shampooing 
are  good  sleepers;  indeed  the  writer  never,  in  the  prosecution 
of  his  inquiries,  heard  of  one  who  was  not. 

The  efficacy  of  the  Turkish  bath  is  greatly  enhanced  if  it 
can  be  had  jusl  before  going  to  bed,  for  the  sleep  which  natu- 
rally follows  its  use  is  continued  uninterruptedly  during  the 
night.  This  can  only  be  accomplished,  of  course,  by  having 
the  bath  at  home;  and  the  writer  can  speak  from  personal 
experience,  having  used  for  some  time  in  his  own  house  the 
"  Matlock  Domestic  Turkish  Bath,"  invented  by  his  friend  Dr. 
Thomas  Maccall,  formerly  assistant  physician  to  Smedley's 
Institution,  Matlock.  It  consists  of  a  small  chamber  contain- 
ing a  couch  for  reclining  on,  with  heating  apparatus,  and 
graduated  taps  for  controlling  the  heat  at  will.  Any  tem- 
perature up  to  200°  Fahr.  can  be  obtained  quickly  by  simply 
regulating  the  quantity  of  gas  used;  and  the  heat  may  be 
as  rapidly  lowered,  so  that  the  one  apartment  combines  the 
use  of  the  three  or  four  rooms  usually  met  with  in  a  public 
bath.  The  arrangements  are  of  a  simple  kind,  and  are  easily 
and  safely  controlled  by  the  bather.  The  ventilation  is  per- 
fect, the  bath  is  quite  portable,  and  occupies  no  more  space 
in  a  room  than  an  ordinary  bed.  It  is  so  constructed  that  a 
small  chamber  can  be  added,  fitted  with  cold  and  hot  water, 
the  latter  heated  from  the  same  source  as  the  bath,  so  that  it 
forms  in  itself  a  complete  Turkish  bath. 

Various  substitutes  for  the  Turkish  bath  are  in  use,  but 
they  all  fall  far  short  of  the  original  in  point  of  efficacy.  Ex- 
amples are  to  be  found  in  the  lamp  bath,  or  in  the  old  Malvern 
gas  bath,  which  resemble  each  other  closely.  The  bather  sits 
upon  a  wooden  chair,  surrounded  by  several  thick  blankets 
securety  fastened  round  his  neck,  a  safety  spirit  lamp  or  gas 
arrangement  is  lighted  underneath  the  chair,  and  perspira- 
tion soon  commences.  After  it  has  continued  for  fifteen  or 
twenty  minutes  he  is  released,  takes  a  hot  soap  bath,  and 


294  Insomnia  and  its   Therapeutics. 

finishes  with  a  cold  shower  bath  or  cold  sponging1.  A  too 
frequent  practice  is  the  use  of  methylated  spirit  in  a  gallipot, 
without  any  wick  or  other  precaution  for  safety.  The  la- 
mented death  of  Dr.  Carpenter,  from  an  accident  arising  out 
of  an  arrangement  of  this  kind,  ought  not  to  be  without  its 
warning. 

ELECTRICITY. 

This  remed3T,  whether  in  the  form  of  central  galvanization 
or  general  faradization,  is  often  attended  by  an  improvement 
in  the  quantity  of  sleep.  The  writer  has  frequently  noticed 
this  in  instances  where  it  was  used  without  reference  to  sleep 
at  all,  it  being  remarked  by  relatives  and  friends  as  a  coinci- 
dence; and  it  is  not  surprising  that  it  should  be  so,  since 
Nothnagel  demonstrated  that  cutaneous  electrical  stimula- 
tion was  followed  by  reflex  contraction  of  the  vessels  of  the 
pia  mater.  Mr.  Skene  Keith,  who  has  had  a  somewhat  large 
experience  of  electricity  in  cases  where  its  use  was  not  adopted 
for  the  relief  of  wake  fulness,  has  kindly  summarized  his  ob- 
servations on  this  subject  for  the  writer.  "  During  the  treat- 
ment of  fibroid  tumors  of  the  uterus,  and  of  other  pelvic  con- 
ditions, by  the  passage  of  a  continuous  current  of  electricity 
from  the  abdomen  to  a  sound  placed  in  the  uterine  cavity,  or 
vice  versd,  one  noticed  that  in  quite  a  considerable  number 
of  cases  sleep  is  affected.  In  perhaps  rather  more  than  half 
the  cases  there  is  not  any  change,  but  in  the  great  majority 
of  the  remainder  there  is  a  marked  improvement  in  this  re- 
spect, and  this  before  there  has  been  sufficient  relief  of  the 
symptoms  to  account  for  it.  The  patients  often  fall  asleep 
in  the  afternoon  after  an  application  has  been  made,  and  will 
often  sleep  for  ten  hours  at  night.  In  a  few  cases  the  patients 
did  not  sleep  so  well  as  they  did  before."  From  this  it  follows 
that  electricity  has  the  power  of  lengthening  the  duration  and 
deepening  the  intensity  of  sleep  in  some  persons  in  whom  it  is 
not  abnormal. 

The  writer  has  found  it  beneficial  in  about  three-fourths  of 
the  patients  who  have  used  it  for  inscmnia.  In  the  majority, 
the  improvement  came  slowly,  and  apparently  as  concomitant 
symptoms  were  alleviated;  in  a  few,  it  came  quickly;  while  in 
the  remainder  it  came  not  at  all,  the  remedy  entirely  failing 
to  relieve  the  wakefulness.  Reference  has  been  made  to  this 
subject  elsewhere. 


INDEX. 


ADEQUATE  repose,  39 
Affections  of  the  circulatory  sys- 
tem, 219 

of  the  respiratory  system,  238 
Age,  influence  on  sleep,  41 
Alcohol  as  a  hypnotic,  61 
Alcoholism,  141 
Amenorrhoea,  281 
Ansemia,  cerebral,  130 

conducive  to  sleep,  19 
Aneurism,  aortic,  235 
Angina  pectoris,  228 
Antecedents,  influence  on  sleep,  47 
Aortic  insufficiency,  232 
Asthma,  247 
Ataxy,  locomotor,  138 
Atheroina,  132 
Atropine  in  shock,  76 
Azoturia,  272 

BATHS,  287 

Bladder,  irritability  of  the,  271 

Blood-supply  of  brain,   variation 

of,  11 

Brachialgia,  140 
Brain,  blood-supply  of,  11 

and  nervous  system  during 
sleep,  2 

circulation  during  sleep,  11 

movements  of,  12 
Bromides  in  insomnia,  72 
Bronchitis,  insomnia  in,  245 

CACHEXLZE.  270 

Calculus,  vesical,  274 

Carbonic  acid,  elimination  of,  dur- 
ing sleep,  8 

Cardiac  centres   in    the   medulla 
oblongata,  36 

Causation  of  sleep,  11 

Cerebral  arteries,  degeneration  of, 

132 
cells,  difference  in,  30 

Cheyne-Stokes'  respiration,  227 

Children,    position    of    limbs    in 
healthy  sleep,  56 

Chloral,  83 


Chloralism,  145 
Chorea,  67,  115 
Circulation  during  sleep,  7 
Climate,  47 

influence  on  sleep,  47,  60 
Cocainism,  146 
Coffee,  147-148 
Cold  foot-bath,  289 
Congestion,  cerebral,  influence  on 
sleep,  33 

cerebral,  127 
Constipation,  182 
Convalescence,  132 
Cough,  239 
Croup,  spurious,  254 
Cystitis,  273 

DEPRESSING  emotions,  77 

Depth  of  sleep,  10 

Devices  for  producing  sleep,  48,  69 

Diabetes  rnellitus,  271 

Diagnosis,  54 

Diet,  standard  daily,  212 

Dreams,  25 

difference  in  quality  of,  26 
Dukes,  Dr.,  of  Rugby,  his  opinion 

of  time  required  for  sleep,  74 
Durham  on  sleep,  15 
Dysmenorrhcea,  280 
Dyspepsia,  134-156 

gastric,  156 

gastric,  causes,  157 

gastric,  symptoms,  168 

gastric,  treatment,  171 

intestinal,  178 

overfeeding  a  cause  of,  165 

symptoms  of,  168 

underfeeding  a  cause  of,  165 
Dyspnoea,  225,  241 

ECZEMA,  treatment,  216 
Effects  of  sleep  upon  the  body,  7 
Electricity,  294 

in  neurasthenia,  95 
Emotions,  depressing,  77 
Emphysema,  249 


296 


Index. 


Enteric  fever,  261 
Epilepsy,  118 

FEVERS,  256 

Food,  constituents  of,  212 

GOUT,  195 
acute,  199 
causes,  206 
irregular,  200 
pathogeny  of,  195 
treatment,  210 

HABIT  of  sleep,  44 

Hay  fever,  249 

Hearing  during  sleep,  5 

Heart,  fatty  degeneration  of  the, 

233 

Herpes  zoster,  140 
History  of  case,  47 
Hot  bath,  the,  290 
Hours  for  exercise  and  sleep  in 

children,  73 
Hyperaemia,  126 

of  the  nervous  centres,  dimi- 
nution of,  68 
Hyperpyrexia,  242 
Hypnotics,  72    . 

action  of,  61 
Hypnotism,  26, 
Hypochondriasis,  104 
Hysteria,  101 

IDIOTS,  sleep  of,  21 

Incontinence  of  urine,  275 

Insanity,  108 

Insomnia  and  its  therapeutics,  1 
and  nightmare,  121 
and  night-terrors,  122 
and  somnambulism,  123 
baths  in,  287 
causes,  49 
definition,  28 
diagnosis,  54 
electricity  in,  294 
frequency  at  different  ages,  53 
from  amenorrhcea,  281 
from  angina  pectoris,  228 
from  Cheyne-Stokes'  respira- 
tion, 227 
from  cough,  239 
from  depressing  emotions,  77 
from  dysiiienorrhcea,  etc.,  280 
from  dyspnoea,  225,  241 
from  hyperpyrexia,  242 
from  incontinence  of  urine,  275 
from  irritability  of  the  blad- 
der, 271 

from  overwork,  64 
from  pain,  242 
from  palpitation,  220 


Insomnia  from  shock,  74 

from  tea  and  coffee,  147 

from  tobacco,  154 

from  uterine  displacements, 
281 

from  vesical  calculus,  274 

general  remarks  on,  28 

in  alcoholism,  141 

in  aortic  aneurism,  235 

in  aortic  insufficiency,  232 

in  asthma,  247 

in  atheroma,  132 

in  azoturia,  272 

in  bronchitis,  245 

in  cachexige,  270 

in  cerebral  anaemia,  130 

in  cerebral  congestion,  127 

in  children,  73 

in  chloralism,  145 

in  chorea,  115 

in  cocainism,  146 

in  convalescence,  132 

in  cystitis,  273 

in  diabetes  mellitus,  271 

in  dyspepsia,  134,  156 

in  emphysema,  249 

in  enteric  fever,  261 

in  epilepsy,  118 

in  fatty  degeneration  of  the 
heart,  233 

in  fevers,  256 

in  functional  disorders  of  the 
liver,  188 

in  gout,  195 

in  hay  fever,  249 

in  hepatitis,  193 

in  hypertrophy  of  the  pros- 
tate, 273 

in  hypochondriasis,  104 

in  hysteria,  101 

in  insanity,  108 

in  intra-cranial  tumors,  136 

in  jaundice,  192 

in  laryngismus  stridulous,  253 

in  locoiiiotor  ataxy,  138 

in  mania,  110 

in  measles,  263 

in  melancholia,  112 

in  migraine,  120 

in  mitral  insufficiency,  230 

in  morphinism,  143 

in  myelitis,  138 

in  rnyxcedema,  114 

in  neuralgia,  139 

in  neurasthenia,  85 

in  paralysis  agitans,  116 

in  phthisis  pulmonalis,  251 

in  pleuritis,  253 

in  pneumonia,  250 

in  prostatitis,  272 

in  pruritis  senilis,  135 


Index. 


297 


Insomnia  in  pyelitis,  273 
in  rheumatism,  265 
in  rickets,  266 
in  scarlet  fever,  263 
in  spinal  meningitis,  137 
in  spurious  croup,  274 
in  syphilis,  278 
in  typhus  fever,  256 
in  whooping-cough,  243 
in  wry-neck,  118 
of  menstrual  periods,  279 
of  pregnancy,  284 
of  puberty  in  females,  279 
of  the  menopause,  282 
of  the  puerperium,  285 
peculiar  to  females,  279 
prognosis,  55 
remarks  on,  28 

treatment,   56,  68,  76,   89,   102 
et  seq. 

Intestinal  worms,  187 

JAUNDICE,  192 

LAMB,  CHARLES,  on  early  rising, 

44 

Laryngismus  stridulous,  253 
Liver,  functional  disorders  of,  188 
Living,  mode  of,  influence  on  sleep, 

146 

Locomotor  ataxy,  140 
Lumbago,  140 

MANIA,  110 

Measles,  263 

Medulla,     condition    of,     during 

sleep,  8 
Melancholia,  112 

treatment  of,  113 
Meningitis,  spinal,  137 
Menopause,  780 
Men    require     less     sleep     than 

w.omen,  40 

Menstrual  periods,  279 
Methods  of  life  as  affecting  sleep, 

46 

Migraine,  120 
Mitral  insufficiency,  230 
Morphinism,  243 
Motor  centres  during  sleep,  4 
Music,  benefit  from,  68 
Myelitis,  138 
Myxoedema,  114 

NERVOUS   centres,    calming   and 
strengthening  them,  71 

system  during  sleep,  2 
Neuralgia,  139 
Neurasthenia,  electricity  in,  95 

stimulants  in,  92 
Normal  metabolism,  32 


OCCUPATION,  influence  on  sleep,  45 
Opium,  77 

Ovarian  neuralgia,  140 
Overfeeding,  evils  of,  65 
Overwork,  64 

evils  of,  in  children,  67 
Oxygen  taken  in  during  sleep,  9 

theory  of  sleep,  22 

PAIN,  242 

Palpitation,  220 

Paralysis  agitans,  116 

Parturition,  285 

Pathological  conditions  during 
sleep,  8 

Periodicity  of  sleep,  24 

Phosphorus,  76,  82 
in  shock,  76 

Phthisis  pulmonalis,  251 

Pillows  for  sleep,  32 

Pleuritis,  253 

Pneumonia,  250 

Pregnancy,  284 

Prescriptions,  71,  73,  77,  82,  83,  84, 
97,  99,  100,  103,  107,  111,  113,  116, 
118, 121, 123, 129,  130, 132,  135,  136, 
138, 143,  145,  153, 175, 177, 181, 185, 
186, 191,  193,  213,  215, 217, 225,  231, 
235,  245,  247,  251,  252.  260,  262,  277, 
280,  283,  286 

Prognosis,  value  of  sleep  in,  55 

Prostate,  hypertrophy  of  the,  273 

Prostatitis,  272 

Pruritus  ani,  treatment,  216 
senilis,  135 

Puberty  in  females,  279 

Puerperium,  285 

Pyelitis,  274 

RECUPERATION,    sleep   favorable 

for,  3 

Reflexes  during  sleep,  10 
Respiration  during  sleep,  8 
Rheumatism,  265 

SALT  bath,  289 
Scarlet  fever,  263 
Sciatica,  140 

Season,  influence  on  sleep,  47 
Seasons  as  related  to  sleep,  47 
Secretions  during  sleep,  9 
Sex,  influence  on  sleep,  40 
Shock,  74 

treatment  of,  76 

Sleep,  absence  of  stimuli  as  cause 
of,  23 

amount  required,  42 

and    sleeplessness,   conditions 
influencing,  40 

as  a  measure  of  possible  work, 
67 


298 


Index. 


Sleep,  by  suggestion,  24 

causation,  2,  11 

cerebral  hyperseuiia  incompat- 
ible with,  14 

cerebral  slight  anjeinia  condu- 
cive to,  19 

condition  of  nervous  system 
during,  2 

conditions  favoring,  29,  57 

depth  of,  10' 

effects  of  impure  blood  on,  32 

effects  of  leucomaines  on,  21 

effects  of  light  on,  31 

effects  of  noise  on,  31 

effects  of  pain  on,  32 

effects  of  smells  on,  31 

effects  of  vascular  tension  on, 
35 

effects  of  waste  products  on,  20 

effects  on  circulation.  7 

effects  on  respiration,  8 

effects  on  temperature,  9 

effects  on  the  secretions,  9 

favors  recuperation,  3 

habit  of,  44 

importance  of,  29 

in  church,  23 

insufficient,  36 

mode  of  incursion,  4 

onset,  gradual,  4 

onset  of,  4 

oxygen  theory  of,  22 

periodicity  of,  24 

physiology  of,  1 
Sleeping  sickness,  19 
Sleeplessness.    See  Insomnia 
Smell  during  sleep,  6 
Somnambulism,  26,  123 
Sound  nervous  structures,  29 
Spasmodic  neuroses,  114 
Spinal  douche,  288 
Spray  or  needle  baths,  288 
Stimulants  in  neurasthenia,  92 
Strychnine  in  insomnia,  76,  82 


Sweating  during  sleep,  9 
Syphilis,  268 

TASTE  during  sleep,  7 

Tea  and  coffee,  constituents  of,  147 
and  coffee,  insomnia  from,  147 
drinkers,  150 

Teas,  classification  of,  153 
commercial,  153 

Temperament,  influence  on  sleep, 
43 

Temperature  during  sleep,  9 

Thyroid  gland  regulating  blood- 
supply  of  the  brain,  19 

Tobacco,  154 

Tonics,  60,  71 

Touch,  sense  of,  during  sleep,  7 

Treatment,  56 

Tumors,  intra-cranial,  136 

Turkish  bath,  the,  291 
use  of,  70 

Turpentine  for  insomnia,  72 

Typhus  fever,  256 

UNDERFEEDING,  evils  of,  165 
Uterine  displacements,  281 

VASCULAR  tension,  35 
Vaso-motor  centres  in  the  medulla 

oblongata,  36 

nerves,  restoring  tone  to,  71 
Vital  alkaloids,  21 

WASTE  products  during  sleep,  20 

Wet  pack,  the,  289 

Whooping  cough,  243 

Women  need  more  sleep  than  men, 

40 

Wood-carving,  benefit  from,  68 
Worms,  intestinal,  187 
Worry,  78 

treatment  of,  80 
Wry-neck,  118 


University  of  California 

SOUTHERN  REGIONAL  LIBRARY  FACILITY 

Return  this  material  to  the  library 

from  which  it  was  borrowed. 


PR.NTEOIN  U.S.A.  CAT.   NO.   24    161 


A    000510519    2 


3  1970007590174 


WML88 


1891 
:«Iac  far  lane,  Alexander  W 

Insomnia  and  its  therapeutics. 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


